NC Medicaid maintains a Point-of-Sale (POS) vaccine rate file and will begin publishing the POS vaccine rate file on the Outpatient Pharmacy Services website under Reimbursement in January 2024. The POS vaccine rate file is based on NCPDP units and is updated as vaccines are added or discontinued for coverage in the POS setting.
NC Medicaid has been notified that NC Medicaid Managed Care plans may be reimbursing vaccine POS claims differently from the State. The NC Medicaid Managed Care plans are working to review their vaccine POS claims and reprocess. NC Medicaid reimburses vaccines at Wholesale Acquisition Cost (WAC) + 3% in the POS setting.
Currently, the NC Medicaid Managed Care plans may not cover all vaccines that NC Medicaid Direct covers at POS; however, beginning Jan. 20, 2024, NC Medicaid Managed Care plans will begin covering vaccines at POS in the same manner as NC Medicaid Direct. In the interim, pharmacy providers should refer to communications from the beneficiaries’ plan for POS vaccine claim submission guidance.
- AmeriHealth Caritas North Carolina, Inc.
- Carolina Complete Health, Inc.
- Healthy Blue of North Carolina
- United Health Care of North Carolina, Inc.
- WellCare Health Plan
Based on updated CMS guidance related to the PREP Act, NC Medicaid will begin covering pharmacy POS claims for COVID-19 vaccines for beneficiaries ages 3 years and up through Dec. 31, 2024, with an effective date of Sept. 11, 2023. A revision is being made to the NC Medicaid COVID-19 Vaccine and Reimbursement Guidelines for 2023-2024 to reflect this as well.
As referenced in Vaccine Immunization Claims Can Be Submitted on Pharmacy Claims for NC Medicaid Direct Beneficiaries, In 2016, the Department of Public Health prohibited pharmacies from participating in the Vaccine for Children program, hence Medicaid only reimburses vaccinations by pharmacist immunizers to Medicaid beneficiaries 19 years of age and older (exception is made for COVID-19 vaccines as set forth by the 9th amendment to the PREP Act for the duration of its effect, also found in the Federal Emergency PREP Act).
Claims will deny if the beneficiary is less than 19 years of age unless the claim is pre-approved for pharmacy administration reimbursement OR if the vaccine administered is unapproved for administration by a pharmacy immunizer.
COVID-19 Pharmacy Coverage Information
| Drug Description | Effective Date | NDCs | Dose | Age Span (years) |
|---|---|---|---|---|
| PFIZER COVID 2023-24 (6M-4Y) EUA | 9/11/2023 | 59267-4315-01 59267-4315-02 | 0.3 mL | 3-4 |
| PFIZER COVID 2023-24 (5-11Y) EUA | 9/11/2023 | 59267-4331-01 59267-4331-02 | 0.3 mL | 5-11 |
| MODERNA COVID 23-24 (6M-11Y) EUA | 9/11/2023 | 80777-0287-07 80777-0287-92 | 0.25 mL | 3-11 |
| COMIRNATY 2023-24 (12Y UP) | 9/11/2023 | 00069-2392-01 00069-2392-10 00069-2362-01 00069-2362-10 | 0.3 mL | 12 and up |
| SPIKEVAX 2023-24 (12Y UP) | 9/11/2023 | 80777-0102-01 80777-0102-93 80777-0102-96 80777-0102-04 80777-0102-95 | 0.5 mL | 12 and up |
| NOVAVAX COVID 2023-24 VL (EUA) | 9/11/2023 | 80631-0105-01 80631-0105-02 | 0.5 mL | 12 and up |
Two new COVID-19 vaccines were released and are now covered at POS with the effective date of Nov. 13, 2023.
| Drug Description | Effective Date | NDCs | Dose | Age Span (years) |
|---|---|---|---|---|
| COMIRNATY 2023-24 (12Y UP) SYRG | 11/13/2023 | 00069-2377-01 00069-2377-10 | 0.3 mL | 12 and up |
Additionally, NCTracks is working to reprocess claims for COVID-19 vaccines between Sept. 11, 2023, and Oct. 18, 2023, that did not pay the correct $65 administration fee for COVID-19 vaccines. No action is needed by providers to initiate the reprocessing.
Contact
NCTracks Call Center: 800-688-6696