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Commissioner Approved Fee Schedule - FY 2019-20 <br />* Any fee changes will be included in this column; <br />a blank beside each fee means there is no fee change in FY 2019-20 Commissioner Approved Fee Schedule <br />Department/Program Description Current Fee <br />Commissioner Approved <br />Fee Change for <br />FY 2019-20* <br />Last <br />Revision <br />90621 Meningococcal recombinant lipoprotein vaccine, <br />serogroup B, 2 or 3 dose schedule - TRUMENBA $248.00 $161.00 2019 <br />Medicaid only 90621SL Meningococcal recombinant lipoprotein vaccine, <br />serogroup B, 2 or 3 dose schedule - TRUMENBA $0.00 2019 <br />90632 Hepatitis A vaccine, adult dose - HAVRIX $45.00 $79.00 2019 <br />Medicaid only 90632SL Hepatitis A vaccine, adult dose - HAVRIX $0.00 2019 <br />90633 Hepatitis A vaccine, pediatric/adolescent dose, 2 <br />dose - HAVRIX $25.00 $37.00 2019 <br />Medicaid only 90633SL Hepatitis A vaccine, pediatric/adolescent dose, 2 <br />dose - HAVRIX $0.00 2019 <br />90636 Hepatitis A and Hepatitis B recombinant vaccine, 3 <br />doses - TWINRIX $102.00 $117.00 2019 <br />Medicaid only 90636SL Hepatitis A and Hepatitis B recombinant vaccine, 3 <br />doses - TWINRIX $0.00 2019 <br />90647 Hemophilus Influenzae B vaccine (Hib), PRP- <br />OMP conjugate, 3 dose - PedVaxHIB $40.00 2018 <br />Medicaid only 90647SL Hemophilus Influenzae B vaccine (Hib), PRP- <br />OMP conjugate, 3 dose - PedVaxHIB $0.00 2019 <br />90648 Hemophilus Influenzae B vaccine (Hib), PRP-T <br />conjugate, 4 dose - ActHIB $26.00 2018 <br />Medicaid only 90648SL Hemophilus Influenzae B vaccine (Hib), PRP-T <br />conjugate, 4 dose - ActHIB $0.00 2019 <br />90649 Gardasil $162.00 Delete fee 2015 <br />Medicaid only 90649SL Gardasil $0.00 Delete fee 2016 <br />90651 <br />Human Papillomavirus vaccine types 6, 11, 16, 18, <br />31, 33, 45, 52, 58, nonavalent (HPV), 2 or 3 dose - <br />GARDASIL 9 $180.00 $225.00 2019 <br />Medicaid only <br />90651SL <br />Human Papillomavirus vaccine types 6, 11, 16, 18, <br />31, 33, 45, 52, 58, nonavalent (HPV), 2 or 3 dose - <br />GARDASIL 9 $0.00 2019 <br />90654 Intradermal flu vaccine $20.00 Delete fee 2012 <br />90655 Preservative free influenza vaccine 6-35 mo $17.00 Delete fee 2015 <br />Medicaid only 90655SL Preservative free influenza vaccine 6-35 mo $0.00 Delete fee 2016 <br />90656 Preservative free influenza vaccine $18.00 Delete fee 2012 <br />Medicaid only 90656SL Preservative free influenza vaccine $0.00 Delete fee 2016 <br />90657 Influenza Split 6-35 mo.$14.00 Delete fee 2009 <br />64