Effective with date of service Nov 1, 2021, Medicaid and NC Health Choice programs cover pneumococcal 15-valent conjugate vaccine suspension for intramuscular injection (Vaxneuvance™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 90671 - Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use.
Strength/Package Size: Suspension for injection (0.5 mL dose), supplied as a single-dose prefilled syringe.
Indicated for active immunization for the prevention of invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F and 33F in adults 18 years of age and older.
Recommended Dose: Administer a single 0.5 mL dose. See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code required for billing is: Z23 - Encounter for immunization
- Providers must bill with HCPCS code: 90671 - Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use
- One Medicaid and NC Health Choice unit of coverage is: 0.5 mL (1 dose)
- The maximum reimbursement rate per unit is: NDC specific SMAC rate. See fee schedule for current rate.
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 00006-4329-01, 00006-4329-02, 00006-4329-03
- 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 Call Center: 800-688-6696