Effective with date of service May 13, 2021, the Medicaid and NC Health Choice programs cover Diphtheria and Tetanus Toxoids and Acellular Pertussis, Inactivated Poliovirus, Haemophilus b Conjugate and Hepatitis B Vaccine Suspension for Intramuscular Injection (Vaxelis™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 90697 - Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular use.
Vaxelis™ is available as a suspension for injection (0.5 mL dose) in single-dose vials and prefilled syringes.
Vaxelis™ is indicated for active immunization to prevent diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B, and invasive disease due to Haemophilus influenzae type b. Vaxelis™ is approved for use as a 3-dose series in children from 6 weeks through 4 years of age (prior to the 5th birthday).
Recommended Dose: The 3-dose immunization series consists of a 0.5 mL intramuscular injection, administered at 2, 4 and 6 months of age. See full prescribing information for further detail.
Vaxelis™ will be covered as part of the Vaccines for Children program as of July 1, 2021.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code(s) required for billing is/are: Z23 - Encounter for immunization
- Providers must bill with HCPCS code: 90697 - Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular use
- One Medicaid and NC Health Choice unit of coverage is: 0.5 mL
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 63361-0243-10, 63361-0243-58, 63361-0243-15, 63361-0243-88
- The NDC units should be reported as “UN1”
- For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update and PADP Clinical Coverage Policy 1B, Attachment A, H.7 on Medicaid's website.
- Providers shall bill their usual and customary charge for non-340B drugs
- PADP reimburses for drugs billed for Medicaid and NC Health Choice beneficiaries by 340B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340B purchasing agreement by appending the “UD” modifier on the drug detail.
- The fee schedule for the PADP is available on Medicaid's PADP webpage.
Contact
NCTracks Call Center: 800-688-6696