SPECIAL BULLETIN COVID-19 #260: NC Medicaid Pharmacy Point-of-Sale Billing for Pharmacist-Prescribed Paxlovid FDA authorizes Paxlovid for treatment of COVID-19 to be prescribed by pharmacists
The July 6, 2022 FDA Statement authorizes state-licensed pharmacists to prescribe Paxlovid. It is the responsibility of the pharmacist to prescribe Paxlovid in accordance with conditions of this guidance from the FDA.
Only Clinical Pharmacist Practitioners (CPPs) are enrolled as Medicaid providers in North Carolina. This means non-CPP pharmacists prescribing Paxlovid must use the pharmacy NPI as the prescriber on point-of-sale (POS) pharmacy claims submitted to NC Medicaid. Using the pharmacy NPI will avoid denials for the non-enrolled provider claim rejection. A State standing order will not be issued for Paxlovid.
In addition to the above, the following is applicable to Paxlovid POS claims:
- Reimbursement will be the ingredient cost (currently $0.00) plus the professional dispensing fee.
- No copay will be collected from the member, because Paxlovid is for treatment of COVID-19.
- Pharmacist must enter the COVID-19 diagnosis on the claim, to bypass the cost-sharing requirement as the claim adjudicates in NCTracks. If the diagnosis is not entered, the claim will incorrectly return a copay to be collected from the member. This applies to NC Medicaid Direct claim requirements. Refer to Managed Care Plans for claim requirements in managed care plans.
- FDA authorization is effective July 6, 2022. NCTracks system readiness for claims processing is anticipated by July 18, 2022, and will be effective back to July 6. After claims processing is active, retrobilling back to the July 6, 2022, start date will be covered. This applies to NC Medicaid Direct claim requirements. Refer to Managed Care Plans for claim requirements in managed care plans.
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