Effective with date of service Oct. 3, 2022, the Medicaid and NC Health Choice programs cover monkeypox vaccine, live, non-replicating suspension for subcutaneous and intradermal injection (Jynneos™) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 90611 - Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL dosage, suspension.
Strength/Package Size(s): Each vial contains a single dose (0.5 mL) for subcutaneous injection or up to 5 doses (0.1 mL each) for intradermal injection.
Indicated for prevention of monkeypox disease in those determined to be at high risk for infection.
***PREP Act 10/2022***
The U.S. Department of Health and Human Services (HHS) has announced an amendment under the Public Readiness and Emergency Preparedness Act (PREP Act) declaration that broadens the pool of qualified healthcare professionals authorized to administer monkeypox vaccines and therapeutics licensed (INCLUDING PHARMACISTS AND PHARMACY PERSONNEL), approved or authorized by the U.S. Food and Drug Administration (FDA) during a federal, regional state or locally declared emergency. The Prep Act amendment can be found on the HHS Administration for Strategic Preparedness and Response Monkeypox webpage.
***Emergency Use Authorization 8/9/2022***
The US Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for the emergency use of Jynneos for:
- Individuals less than 18 years of age for subcutaneous injection only. Administer two doses (0.5 mL each) 4 weeks apart.
- Individuals 18 years of age and older for intradermal injection only. Administer two doses (0.1 mL each) 4 weeks apart.
See full prescribing information for further detail. If you have any questions about product-specific information, please contact the Immunization Branch help desk at 877-873-6247 and press option 6.
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: 90611 - Monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous use
- One Medicaid and Health Choice unit of coverage is: 0.5 mL
- The maximum reimbursement rate per unit is: N/A because the drug is distributed from the National Stockpile (reimbursement will be provided for the administration of the vaccine)
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs is/are: 50632-0001-01, 50632-0001-02
- 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.
Important Claims Information:
- Medicaid and NC Health Choice will reimburse at the standard administration rate for subcutaneous or intradermal vaccine
- Claims must have appropriate NDCs that correspond to the vaccine used for administration and corresponding CPT code
- Claims must contain both administration codes and vaccine codes to pay
- Vaccine codes should be reported as $0.00
- Medicaid and NC Health Choice do not allow copays to be charged for the Jynneos vaccine
- Jynneos vaccine is exempt from the Vaccines For Children (VFC) program
- Pharmacies may administer Jynneos vaccine to any Medicaid or NC Health Choice beneficiary 19 years and older
- CG modifier should be appended to ALL Jynneos vaccine AND administration claims submitted by a pharmacy participating in the immunization program
- TJ modifier should be appended to all NC Health Choice claims (through 18 years)
- EP modifier should be appended to all non-NC Health Choice (only Medicaid beneficiaries) younger than 21 years of age
Contact
NCTracks Call Center: 800-688-6696