Author: CSRA
Effective with date of service Jan. 8, 2018, the North Carolina Medicaid and NC Health Choice (NCHC) programs covers hepatitis B vaccine (recombinant), adjuvanted solution for intramuscular injection (Heplisav-B) for use in the Physician’s Drug Program (PDP) when billed with HCPCS code 90739 - Hepatitis B vaccine (HepB), adult dosage, two dose schedule, for intramuscular use.
Heplisav-B is available as a solution for injection supplied as a 0.5 mL single-dose vial and is indicated for the prevention of infection caused by all known subtypes of hepatitis B virus in adults 18 years of age and older.
The recommended dose is two doses (0.5 mL each) administered intramuscularly one month apart.
See full prescribing information for further detail.
For Medicaid and NCHC Billing
- The ICD-10-CM diagnosis code required for billing is Z23 - Encounter for immunization.
- Providers must bill with HCPCS code 90739 - Hepatitis B vaccine (HepB), adult dosage, two dose schedule, for intramuscular use.
- One Medicaid unit is 0.5 mL. NCHC bills according to Medicaid units.
- The maximum reimbursement rate per unit is $118.45.
- Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs are 43528-0002-01 and 43528-0002-05.
- 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 PDP Clinical Coverage Policy No. 1B, Attachment A, H.7 on North Carolina Medicaid’s 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 Medicaid’s PDP web page.
CSRA 1-800-688-6696