Effective with date of service Oct. 1, 2023, NC Medicaid Direct and NC Medicaid Managed Care cover Japanese encephalitis vaccine, inactivated, adsorbed suspension for intramuscular injection (Ixiaro) for use in the Physician Administered Drug Program (PADP) when billed with HCPCS code 90738 - Japanese encephalitis virus vaccine, inactivated, for intramuscular use.
Strength/Package Size: Suspension for injection supplied in 0.5 mL single dose syringes.
Japanese encephalitis vaccine, inactivated, adsorbed suspension for intramuscular injection is indicated for active immunization for the prevention of disease caused by Japanese encephalitis virus (JEV). Ixiaro is approved for use in individuals two months of age and older.
Recommended Dose:
Primary Series
- Children 2 months to <3 years of age: 0.25 mL; 2 doses, 28 days apart
- Children and adolescents 3 to <18 years of age: 0.5 mL; 2 doses, 28 days apart
- Adults 18 through 65 years of age: 0.5 mL; 2 doses, 7 days apart or 2 doses, 28 days apart
- Adults older than 65 years of age: 0.5 mL; 2 doses, 28 days apart
Booster Dose:
A booster dose (third dose) may be given at least 11 months after completion of the primary immunization series if ongoing exposure or re-exposure to JEV is expected.
- Children from 14 months to less than three years of age should receive a single 0.25 mL booster dose.
- Individuals three years of age and older should receive a single 0.5 mL booster dose.
See full prescribing information for further detail.
For Medicaid Billing
- The ICD-10-CM diagnosis code required for billing is: Z23 - Encounter for immunization
- Providers must bill with HCPCS code: 90738 - Japanese encephalitis virus vaccine, inactivated, for intramuscular use
- One Medicaid unit of coverage is: 0.5 mL
- 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: 42515-0001-01, 42515-0002-01
- The NDC units should be reported as "UN1"
- For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update.
- For additional information regarding NDC claim requirements related to the PADP, refer to the PADP Clinical Coverage Policy 1B, Attachment A, H.7 on NC Medicaid's website.
- Providers shall bill their usual and customary charge for non-340B drugs.
- PADP reimburses for drugs billed for Medicaid 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 their actual 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 the NC Medicaid Fee Schedule & Covered Code portal.
ICD-10-CM Manual. American Medical Association, 2023 manual.
*Information current as of Sept. 26, 2023, and is not a substitute for professional judgment. For full prescribing information, please refer to current package insert or other appropriate sources prior to making clinical judgments.
Contact
NCTracks Call Center: 800-688-6696