Prior Auth Required

90657 - [5ml vial 0.25 ml dose]) $25.00 (Pentacel) $89.99

This procedure appears on the selected insurer prior authorization source.

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Prior authorizationPrior Auth Required
Procedure / Service[5ml vial 0.25 ml dose]) $25.00 (Pentacel) $89.99
Procedure / Service Description

Diphtheria, tetanus toxoids, acellular pertussis vaccine, - Influenza virus vaccine, trivalent (IIV3), split virus, 0.25mL haemophilus influenza Type B, and poliovirus vaccine, dosage for intramuscular use (Afluria, Fluvarix, Fluvirin, Fluzone inactivated (DTaP - Hib - IPV), for intramuscular use 90657 [5ml vial 0.25 ml dose]) $25.00 90698 (Pentacel) $89.99

Likely documents
  • Confirm benefit details
  • Submit clinical notes if requested by the plan
Next actions
  • Confirm the current plan policy before submission.
  • Use the insurer authorization workflow for this listed code.