Influenza Vaccine and Reimbursement Guidelines for 2025-2026 for NC Medicaid

This bulletin applies to both NC Medicaid Direct and NC Medicaid Managed Care.

Vaccine strains for the 2025-26 influenza vaccines were selected by the Food and Drug Administration’s Vaccines and Related Biologic Products Advisory Committee (VRBPAC) based on the World Health Organization (WHO) recommended Northern Hemisphere 2024–25 influenza vaccine composition. For details on the 2025-2026 influenza vaccines, visit the Centers for Disease Control (CDC) Flu Season web page.

NC Immunization Program/Vaccines for Children

Under NC Immunization Program/Vaccines for Children (NCIP/VFC) guidelines, the NC Division of Public Health (DPH) Immunization Branch distributes all childhood vaccines that are recommended by the Advisory Committee on Immunization Practices (ACIP) to local health departments, Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC), hospitals and private providers.

For the 2025-2026 influenza season, NCIP/VFC influenza vaccines are available at no charge to providers for children ages 6 months through 18 years who are eligible for the VFC program, according to the NCIP coverage criteria. The current NCIP coverage criteria and definitions of VFC categories can be found on the DPH Immunization Branch web page.

For providers interested in enrolling in the VFC program, information can be found on the CDC information page and the NC DPH website.

Eligible VFC children include ALL NC Medicaid beneficiaries through age 18.

For VFC/NCIP vaccines administered to VFC-eligible children, providers must report only the vaccine code(s) with $0.00. Providers may bill NC Medicaid for the administration fee for Medicaid.

Providers who administer privately purchased vaccines to VFC eligible beneficiaries will NOT be reimbursed for the vaccine and cannot bill the beneficiary for that cost. Only the administration fee(s) will be reimbursed.

Providers must purchase vaccines for beneficiaries who are not VFC-eligible. For Medicaid-eligible beneficiaries ages 19 and older, purchased vaccine and administration costs may be billed to NC Medicaid, according to the guidelines stated in Tables 2 and 3 below. To determine who is eligible for NCIP influenza and other vaccines, visit DPH’s Immunization Branch web page.

Billing/Reporting Influenza Vaccines for Medicaid Beneficiaries

The following tables indicate the vaccine codes that may be either reported (with $0.00 billed) or billed (with the usual and customary charge) for influenza vaccine, depending on the age of the beneficiaries and the formulation of the vaccine. The tables also indicate the administration codes that may be billed, depending on the age of the beneficiaries and the vaccine(s) administered to them.

Note: Specific information on billing all immunization administration codes for Health Check beneficiaries can be found in the Health Check Program Guide available at the NCTracks Provider Policies, Manuals, Guidelines and Forms web page.

If you have any questions or need assistance, please contact the Immunization Branch Help Desk at 877-873-6247.

Table 1.

Influenza Billing Codes for NC Medicaid Beneficiaries Through Age 19 Who Receive VFC Influenza Vaccine. These codes are reported with $0.00.

Vaccine CPT Codes to Report

*NDCs listed on Table 1 are NDCs of packs of vials as distributed by the Division of Public Health. For claims processing, providers should use the NDC listed on the actual vial used for administration as listed at the bottom of this bulletin.

Administrative CPT Codes to Bill

* 90472 will only be used if another vaccine is given in addition to the flu vaccine. Providers may bill more than one unit of 90472 as appropriate.

Table 2.

Influenza Billing Codes for NC Medicaid Beneficiaries Ages 19 through 21

Use the following codes to bill Medicaid for an influenza vaccine purchased and administered to beneficiaries ages 19 through 21.

Note: The VFC/NCIP provides influenza products for recipients ages 6 months through 18 years only. The VFC/NCIP will NOT provide influenza vaccine for recipients ages 19 and older.

Vaccine CPT Codes to Report

Administrative CPT Codes to Report

* 90472 will only be used if another vaccine is given in addition to the flu vaccine. Providers may bill more than one unit of 90472 as appropriate.

Table 3.

Influenza Billing Codes for NC Medicaid Beneficiaries Ages 21 and Older

Use the following codes to bill Medicaid for influenza vaccine purchased and administered to beneficiaries ages 21 and older.

Note: The VFC/NCIP provided influenza products for VFC-age (6 months through 18 years) beneficiaries only. The VFC/NCIP will not provide influenza vaccine for beneficiaries 19 years and older.

Vaccine CPT Code to Report

Administrative CPT Code(s) to Bill

* 90472 will only be used if another vaccine is given in addition to the flu vaccine. Providers may bill more than one unit of 90472 as appropriate.

For beneficiaries ages 21 years and older receiving an influenza vaccine, an evaluation and management (E/M) code cannot be reimbursed to any provider on the same day that injection administration fee codes (e.g., 90471 or 90471 and +90472) are reimbursed, unless the provider bills an E/M code for a separately identifiable service by appending modifier 25 to the E/M code.

Immunization Billing for NC Medicaid from FQHCs and RHCs

For beneficiaries through age 20

If vaccines are provided through the NCIP/VFC, the center/clinic shall report the CPT vaccine codes (with $0.00 billed) under Physician Services National Provider Identifier (NPI) and may bill for the administration codes (CPT procedure codes 90471EP through 90472EP OR 90460EP). This billing is appropriate when only vaccines are provided at the visit, or if vaccines were provided in conjunction with a wellness check. If a core visit was billed, CPT vaccine codes shall be reported (with $0.00 billed) under Physician Services NPI and an administration code shall not be billed.

If purchased vaccines (non-VFC eligible) were administered, the center/clinic may bill the CPT vaccine codes (with their usual and customary charge) under the Physician Services NPI for the vaccines administered and may bill for the administration codes (with the usual and customary charge). This billing is appropriate if only vaccines were given at the visit or if vaccines were given in conjunction with a wellness check. If a core visit was billed, CPT vaccine codes shall be reported (with $0.00 billed) under the Physician Services NPI provider number and the administration codes shall not be billed. For detailed billing guidance, refer to the Health Check Program Guide available at NCTracks Provider Policies, Manuals, Guidelines and Forms web page.

For beneficiaries ages 21 and older

When purchased vaccines are administered, CPT vaccine codes may be billed (with the usual and customary charge) and administration codes may be billed (with the usual and customary charge) under the Physician Services NPI. This is applicable when vaccine administration was the only service provided that visit. When a core visit is billed, the CPT vaccine code shall be reported (with $0.00 billed) under the Physician Services NPI, and an immunization administration code may not be billed.

For influenza vaccine and administration fee rates, refer to the DHB's Physician Administered Drug Program (PADP) and Physician Services Fee Schedule.

Immunization Billing for NC Medicaid Beneficiaries from Immunizing Pharmacies

For beneficiaries ages 3 and older

Update on the VFC Program in Immunizing Pharmacies

Effective Jan. 1, 2025, NC Medicaid will reimburse pharmacy providers for the administration and ingredient cost of the seasonal influenza vaccine at POS for beneficiaries ages 3 and older.  Children ages 3 through 18 that qualify for the VFC Program may go to a pharmacy provider to receive their seasonal influenza vaccine in accordance with the Centers for Medicare & Medicaid Services (CMS) guidance.

Pharmacies must administer a non-VFC seasonal influenza vaccine to qualify for reimbursement. Pharmacy providers authorized under the PREP Act declaration are eligible for Medicaid reimbursement for both the non-VFC influenza vaccine and its administration. Pharmacy providers do not need to be enrolled as a VFC provider to qualify for reimbursement of a non-VFC influenza vaccine.

Updated Seasonal Influenza Vaccines Reimbursement Policy

Pharmacies will be allowed to bill NC Medicaid Direct for vaccines on pharmacy claims at point of sale. Immunizing pharmacists are not required to submit vaccine administration claims on medical 837P or CMS 1500 form, but this will remain an option for immunizing pharmacists who wish to do so. Additional information can be found in the Vaccine Immunization Claims Can Be Submitted on Pharmacy Claims for NC Medicaid Direct Beneficiaries published on Nov. 28, 2022.

The Vaccine Point-of-Sale (POS) Catalogs and Rate Listings is maintained with vaccine POS and rate listing information.

For NC Medicaid Managed Care health plans, pharmacy providers should refer to communications from the beneficiaries’ plan for influenza vaccine claim submission guidance.

Table 4.

Billing Codes to be used by Pharmacist for NC Medicaid Beneficiaries Ages 19 or Older via CMS 1500 or 837P Claims

*The CG modifier must be appended to every vaccine and vaccine administration CPT code used to bill vaccines by pharmacists. The CG modifier identifies a Pharmacy Provider in NCTracks for vaccine claims billing purposes.

Billing Codes to be used by Pharmacists for NC Medicaid Beneficiaries Ages 19 and Older via CMS 1500 or 837P Claims

The CG modifier must be appended to every vaccine and vaccine administration CPT code used to bill vaccines by pharmacists. The CG modifier identifies a Pharmacy Provider in NCTracks for vaccine claims billing purposes.

*Providers may bill more than one unit of 90472 as appropriate. Please note that NDCs are required on vaccine claims.

NDC’s Change Each Year for Influenza Vaccines

Providers are required to use appropriate NDCs that correspond to the vaccine used for administration and corresponding CPT code. Note that not all products and NDCs under their respective CPT codes will be covered.

Influenza vaccines are licensed each year with new NDCs, so it is important to report the correct code for the products you are using to avoid having claims deny with edit 00996 (Mismatched NDC) which will require the claim to be resubmitted with the correct NDC. Below are the influenza vaccine procedure (CPT) codes and corresponding NDCs that should be used for the 2024-2025 influenza season:

CPT and NDC codes for the 2025-2026 Influenza Vaccine Products*

*Please note that for PADP medical claims, the PADP fee schedule is updated monthly with current CPT-NDC combinations and the Vaccine Point-of-Sale (POS) Catalogs and Rate Listings webpage are updated regularly with current NDCs for pharmacy point-of-sale claims.

Contact

NCTracks Call Center, 800-688-6696

Health Plan Pharmacy Lines

Standard Plan Pharmacy Lines

• AmeriHealth: 866-885-1406
• Healthy Blue: 833-434-1212
• Carolina Complete: 833-992-2785
• United Healthcare: 855-258-1593
• WellCare: 866-799-5318

Tailored Plan Pharmacy Lines

• Alliance: 855-759-9300
• Partners: 866-453-7196
• Trillium: 866-245-4954
• Vaya: 800-540-6083