Effective with date of service Nov. 8, 2017, the North Carolina Medicaid program covers zoster vaccine recombinant, adjuvanted, suspension for intramuscular injection (Shingrix) for use in the Physician’s Drug Program (PDP) when billed with CPT code 90750 - Zoster (shingles) vaccine, (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection.
The suspension for injection is supplied as a single-dose vial of lyophilized varicella zoster virus glycoprotein E (gE) antigen component to be reconstituted with the accompanying vial of AS01B adjuvant suspension component. After reconstitution, a single dose of Shingrix is 0.5 mL. Shingrix is indicated for prevention of herpes zoster (shingles) in adults aged 50 years and older. Shingrix is not indicated for prevention of primary varicella infection (chickenpox). The recommended dose of Shingrix is two doses (0.5 mL each) administered intramuscularly according to a schedule of a first dose at month zero followed by a second dose administered anytime between two and six months later.
- ICD-10-CM diagnosis code required for billing is Z23 - Encounter for immunization.
- Providers must bill with CPT code: 90750 - Zoster (shingles) vaccine, (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection.
- One Medicaid unit of coverage is 0.5 mL.
- The maximum reimbursement rate per unit is $144.20.
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs are 58160-0823-11 and 58160-0819-12.
- The NDC units should be reported as “UN1.”
- For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update.
- For additional information regarding NDC claim requirements related to the PDP, refer to the Clinical Coverage Policy No. 1B, Physician Drug Program, Attachment A, H.7 on the Medicaid website.
- Providers shall bill their usual and customary charge for non-340-B drugs.
- PDP reimburses for drugs billed for Medicaid and NCHC beneficiaries by 340-B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340-B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340-B purchasing agreement by appending the “UD” modifier on the drug detail.
- The fee schedule for the PDP is available on the North Carolina Medicaid PDP web page.