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Commissioner Approved Fee Schedule - FY 2020-21 Attachment 4 <br />* Any fee changes will be included in this column; <br />a blank beside each fee means there is no fee change in FY 2020-21 Commissioner Approved Fee Schedule <br />Department/Program Description Current Fee <br />Commissioner Approved <br />Fee Change for <br />FY 2020-21* <br />Last <br />Revision <br />90714 Tetatus and diphteria toxoids (Td) adsorbed, <br />preservative free, for 7 years or older - TENIVAC $35.00 2018 <br />Medicaid only 90714SL Tetatus and diphteria toxoids (Td) adsorbed, <br />preservative free, for 7 years or older - TENIVAC $0.00 2019 <br />90715 Tetanus, diphteria toxoids and acellular pertussis <br />vaccine (Tdap), for to 7 years or older - ADACEL $39.49 2018 <br />Medicaid only 90715SL Tetanus, diphteria toxoids and acellular pertussis <br />vaccine (Tdap), for to 7 years or older - ADACEL $0.00 2019 <br />90716 Varicella virus vaccine (VAR), live - VARIVAX $177.00 2019 <br />Medicaid only 90716SL Varicella virus vaccine (VAR), live - VARIVAX $0.00 2019 <br />90723 <br />Diphteria, tetanus toxoids, acellular pertussis <br />vaccine, Hepatitis B, and inactivated poliovirus <br />vaccine (DTaP-Hep B-IPV) - PEDIARIX $91.00 2018 <br />Medicaid only <br />90723SL <br />Diphteria, tetanus toxoids, acellular pertussis <br />vaccine, Hepatitis B, and inactivated poliovirus <br />vaccine (DTaP-Hep B-IPV) - PEDIARIX $0.00 2019 <br />90732 <br />Pneumococcal polysaccharide vaccine, 23-valent <br />(PPSV23), adult or immunosuppressed patient <br />dosage, when administered to 2 years or older - <br />PNEUMOVAX 23 $107.00 $115.00 2019 <br />Medicaid only <br />90732SL <br />Pneumococcal polysaccharide vaccine, 23-valent <br />(PPSV23), adult or immunosuppressed patient <br />dosage, when administered to 2 years or older - <br />PNEUMOVAX 23 $0.00 2019 <br />90734 <br />Meningococcal conjugate vaccine, serogroups <br />A,C,Y and W-135 quad (MenACWY or MCV4) - <br />MENVEO $119.00 2019 <br />Medicaid only <br />90734SL <br />Meningococcal conjugate vaccine, serogroups <br />A,C,Y and W-135 quad (MenACWY or MCV4) - <br />MENVEO $0.00 2019 <br />90734 <br />Meningococcal conjugate vaccine, serogroups <br />A,C,Y and W-135 quad (MenACWY or MCV4) - <br />MENACTRA $127.00 2018 <br />Medicaid only <br />90734SL <br />Meningococcal conjugate vaccine, serogroups <br />A,C,Y and W-135 quad (MenACWY or MCV4) - <br />MENACTRA $0.00 2019 <br />68