Provider Notice issued 03/11/10

Reimbursement of Gardasil® for Males and Cervarix® for Females
 

The purpose of this notice is to provide information on the department’s reimbursement for the quadrivalent Human Papillomavirus (HPV) vaccine [Gardasil®] for males and the bivalent HPV vaccine [Cervarix®] for females.

Reimbursement of Gardasil® (HPV 4)

Effective October 21, 2009, the U.S. Centers for Disease Control and Prevention (CDC) approved the administration of Gardasil® to males ages 9 through 26. Providers participating in the Vaccine for Children (VFC) Program are now eligible to receive an administration fee of $6.40 for each of the three vaccinations in the Gardasil® series when administered to males 9 through 18 years of age. VFC participating providers should use CPT Code 90649 when billing for the administration of Gardasil®. When billing for males ages 19 through 26, please use modifier SL with CPT Code 90649. Reimbursement will be $149.33 for each of the three doses in the series.

Providers who do not routinely administer vaccinations, and are not enrolled in the VFC Program, may bill for the Gardasil® vaccine provided to patients 9 through 26 years of age by using CPT Code 90649 with the modifier SL. Using the SL modifier will indicate that the provider is being reimbursed by the state for the vaccine. These services will be paid at a maximum rate of $149.33 for each vaccine in the three-dose series.

Reimbursement of Cervarix® (HPV 2)

Effective October 19, 2009, the Food and Drug Administration approved the administration of Cervarix® to females ages 9 through 26. For dates of services, October 19, 2009, through October 31, 2009, providers may bill for the Ceravix® vaccine provided to female patients 9 through 26 years of age by using CPT Code 90650 with the modifier SL. These services will be paid at a maximum rate of $153.10 for each vaccine in the three-dose series.

Effective November 1, 2009, Cervarix® was added to the VFC Program. For dates of service November 1, 2009, and after, providers participating in the VFC Program are now eligible to receive an administration fee of $6.40 for each of the three vaccinations in the Cervarix® series when administered to females 9 through 18 years of age. VFC participating providers should use CPT Code 90650 when billing for the administration of Cervarix®. When billing for females ages 19 through 26, please use modifier SL with CPT Code 90650. Reimbursement will be $153.10 for each of the three doses in the series.

Providers who do not routinely administer vaccinations, and are not enrolled in the VFC Program, may bill for the Cervarix® vaccine provided to patients 9 through 26 years of age by using CPT Code 90650 with the modifier SL. Using the SL modifier will indicate that the provider is being reimbursed by the state for the vaccine. These services will be paid at a maximum rate of $153.10 for each vaccine in the three-dose series.

Additional information regarding the CDC recommendations may be found at:

http://www.hfs.illinois.gov/assets/cdc.pdf

Questions regarding this notice should be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator

Division of Medical Programs