Influenza Vaccine and Reimbursement Guidelines for 2023-2024 for NC Medicaid (Pharmacists)

Vaccine strains for the 2023–24 influenza vaccines were selected by the Food and Drug Administration’s Vaccines and Related Biologic Products Advisory Committee based on WHO’s recommended Northern Hemisphere 2023–24 influenza vaccine composition. For details on the 2023-2024 influenza vaccines, visit the Centers for Disease Control (CDC) Flu Season web page.  

NC Immunization Program/Vaccines for Children (NCIP/VFC)

Under NC Immunization Program/Vaccines for Children (NCIP/VFC) guidelines, the NC Division of Public Health (DPH) Immunization Branch manages and distributes all childhood vaccines that are recommended by the Advisory Committee on Immunization Practices (ACIP) to local health departments, Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC), hospitals and private providers. More information about the VFC program can be found at DPH’s Immunization Branch.

By joint decision of DPH and DHB, immunizing pharmacists are NOT eligible to participate in the VFC program. Immunizing pharmacist providers may only vaccinate to non-VFC Medicaid-eligible beneficiaries aged 19 years and older. Pharmacists will NOT be reimbursed for the cost of the vaccine for any Medicaid beneficiary younger than 19 years of age. 

Billing/Reporting Influenza Vaccines for Medicaid Beneficiaries 

Pharmacy Claims at Point of Sale

Pharmacies will be allowed to bill NC Medicaid Direct for vaccines on pharmacy claims at point of sale. Immunizing pharmacists are not required to submit vaccine administration claims on medical 837P or CMS 1500 form, but this will remain an option for immunizing pharmacists who wish to do so. Additional information can be found in the Vaccine Immunization Claims Can Be Submitted on Pharmacy Claims for NC Medicaid Direct Beneficiaries published on Nov. 28, 2022.

Claims will deny if the beneficiary is less than 19 years of age unless the claim is pre-approved for pharmacy administration reimbursement OR if the vaccine administered is unapproved for administration by a pharmacy immunizer.

Reimbursement rates for vaccines will be WAC+3%, and will be listed on the Outpatient Pharmacy webpage, under the Reimbursement section.  

CPT codes for administration of a vaccine will not be required on the pharmacy claim. Vaccine administration rates will be added to the reimbursement amount of the vaccine and will be reflected on the response transaction.

Administration rates for pharmacy immunizations will remain the same as for all other NC Medicaid recognized medical providers and can be found on the Physician Fee Schedule:

• Administration rate for beneficiaries younger than 21 years is $20.45
• Administration rate for beneficiaries 21 or older is $13.30

Additional information for vaccine administration on pharmacy claims:

• Providers shall bill with the 11-digit vaccine NDC associated with the product administered (best practice is to use the NDC closest to the drug administered)
• Providers shall bill their usual and customary charge for non-340B drugs
• Providers shall bill their actual acquisition charge for 340B drugs in the U&C field
• Dispensing fee will NOT be paid on pharmacy claims for immunization administration
• Claims for vaccines shall be copay exempt
• Vaccine claims submitted by the I/T/U provider will not be reimbursed the OMB Encounter rate (flat rate)
• A delivery fee will not be paid on claims for vaccines

NDC codes for the 2023-2024 Influenza Vaccine Products

Medical Claims via 837P of CMS 1500

The following tables indicate the vaccine codes that may be billed (with the usual and customary charge) for influenza vaccine. The tables also indicate the administration codes that may be billed, depending on the age of the beneficiaries and the vaccine(s) administered to them.

All providers, including pharmacists, will be reimbursed the same amount for the influenza vaccines and administration charges. For influenza vaccine and administration fee rates, refer to the DHB's Physician Administered Drug Program (PADP) and Physician Services Fee Schedule.  

Billing Codes to be used by Pharmacist for NC Medicaid Beneficiaries 19 Years of Age or Older

*The CG modifier must be appended to every vaccine and vaccine administration CPT code used to bill vaccines by pharmacists. The CG modifier identifies a pharmacy provider in NCTracks for vaccine claims billing purposes. 

Billing Codes to be used by Pharmacists for NC Medicaid Beneficiaries 19 Years of Age and Older

The CG modifier must be appended to every vaccine and vaccine administration CPT code used to bill vaccines by pharmacists. The CG modifier identifies a pharmacy provider in NCTracks for vaccine claims billing purposes.  

*Providers may bill more than one unit of 90472 as appropriate.

Detailed information about the regulations regarding pharmacist immunization can be found at Pharmacist Administrated Vaccine and Reimbursement Guidelines published in the October 2016 Medicaid Bulletin. Please note that NDCs are required on vaccine claims. 

NDC's for Influenza Vaccines

Providers are required to use appropriate NDCs that correspond to the vaccine used for administration and corresponding CPT code. Note that not all products and NDCs under their respective CPT codes will be covered.  

Influenza vaccines are licensed each year with new NDCs, so it is important to report the correct code for the products you are using to avoid having claims deny with edit 00996 (Mismatched NDC) which will require the claim to be resubmitted with the correct NDC. Below are the influenza vaccine procedure (CPT) codes and corresponding NDCs that should be used for the 2023-2024 influenza season:

CPT and NDC codes for the 2023-2024 Influenza Vaccine Products

Contact

GDIT, 800-688-6696