Effective with date of service Aug. 1, 2022, the Medicaid and NC Health Choice programs cover measles, mumps, and rubella vaccine, live, suspension for subcutaneous injection (Priorix) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 90707 - Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use.
Strength/Package Size: Priorix is a suspension for injection supplied as a single-dose vial of lyophilized antigen component to be reconstituted with the accompanying prefilled syringe of sterile water diluent component. A single dose after reconstitution is approximately 0.5 mL.
Indicated for active immunization for the prevention of measles, mumps, and rubella in individuals 12 months of age and older.
Recommended Dose: Each dose is approximately 0.5 mL.
- The first dose is administered at 12 through 15 months of age
- The second dose is administered at 4 through 6 years of age
- If Priorix is not administered according to this schedule and two doses of measles-, mumps- and rubella-virus vaccine are recommended for an individual, there should be a minimum of four weeks between the first and second dose
- Priorix may be administered as a second dose to individuals who have received a first dose of another measles, mumps, and rubella virus-containing vaccine
See full prescribing information for further detail.
For Medicaid and NC Health Choice Billing
The ICD-10-CM diagnosis codes required for billing is: Z23 - Encounter for immunization
- Providers must bill with HCPCS code: 90707 - Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use
- One Medicaid and NC Health Choice unit of coverage is: 0.5 mL
- The maximum reimbursement rate per unit is: N/A because vaccine is part of VFC program
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 58160-0824-15, 58160-0831-03
- 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