Effective with date of service Aug. 23, 2021, the Medicaid and NC Health Choice programs cover pneumococcal 20-valent conjugate vaccine, suspension for intramuscular injection (Prevnar 20™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 90677 - Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use.
Strength/Package Size(s): 0.5 mL suspension for intramuscular injection, supplied in a single-dose pre-filled syringe
Indicated for active immunization for the prevention of pneumonia and invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 8, 9V, 10A, 11A, 12F, 14, 15B, 18C, 19A, 19F, 22F, 23F, and 33F in adults 18 years of age and older. Advisory Committee on Immunization Practices recommends Prevnar 20™ be administered to:
- Adults 65 years of age or older who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive a pneumococcal conjugate vaccine (either PCV20 or PCV15). If PCV15 is used, this should be followed by a dose of PPSV23.
- Adults aged 19 years of age or older with certain underlying medical conditions or other risk factors who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive a pneumococcal conjugate vaccine (either PCV20 or PCV15). If PCV15 is used, this should be followed by a dose of PPSV23.
Recommended Dose: Prevnar 20™ is administered as a single dose. Each 0.5 mL dose is to be injected intramuscularly using a sterile needle attached to the supplied pre-filled syringe. See full prescribing information for further detail.
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: 90677 - Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use
- One Medicaid and NC Health Choice unit of coverage is: 0.5 mL
- The maximum reimbursement rate per unit is listed on PADP fee schedule per NDC
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is/are: 00005-2000-01, 00005-2000-02, 00005-2000-10
- 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 web page.
Contact
NCTracks Contact Center: 800-688-6696