NC Medicaid COVID-19 Vaccine Guidelines for 2026-2027

The following information is applicable to NC Medicaid Direct and NC Medicaid Managed Care.

The 2026-2027 vaccine formula targets the JN.1 lineage, with the FDA preferentially recommending the LP.8.1 strain. The available vaccines for this season are updated to target currently circulating variants. For ages 6 months through 17, vaccination is recommended through shared clinical decision making. The CDC recommends the 2026-2027 COVID-19 vaccine for all adults, ages 18 and older.

Summary of NC Medicaid COVID-19 Vaccine Coverage

• Comirnaty®: NC Medicaid covers Comirnaty® for beneficiaries ages five and older. This is available for reimbursement as a medical or pharmacy point-of-sale (POS) claim. 
• Spikevax™: NC Medicaid covers Spikevax™ for beneficiaries ages 6 months and older. This is available as a medical or pharmacy POS claim. Note: pharmacies should refer to state law and individual immunization protocols for age limitations.
• Nuvaxovid® and mNexspike®: NC Medicaid covers Nuvaxovid® and mNexspike® for beneficiaries ages 12 and older. These are available as medical or pharmacy POS claims. 
• No preference for vaccine type: The CDC does not recommend one COVID-19 vaccine over another when multiple age-appropriate vaccines are available.
• Vaccines for Children: COVID-19 vaccines are part of the Vaccines for Children program (VFC) for beneficiaries ages 18 and younger. Beneficiaries ages 18 and younger may receive COVID-19 vaccines at a pharmacy outside of VFC. Refer to section Medicaid Pharmacy Claims Billing for COVID-19 Vaccines for billing guidance.
• Pharmacy Age Restrictions: pharmacies should refer to state law, federal law and individual immunization protocols for age limitations.

Medicaid Medical Claims Billing for COVID-19 Vaccines

• The ICD-10-CM diagnosis code required for billing is Z23 - Encounter for immunization.
• Providers are required to use appropriate NDCs that correspond to the vaccine used for administration and corresponding CPT code. (See table below.)
  • Note: NDCs change with each new formulation for COVID-19 vaccines. Report the correct code for the products to avoid having claims deny with edit 00996 (Mismatched NDC), which will require the claim to be resubmitted with the correct NDC.
• Claims must contain both administration CPT codes and vaccine CPT codes to pay.

Administration CPT codes

• 90471 - Immunization administration: includes one vaccine, percutaneous, intradermal, subcutaneous, or intramuscular injections (single or combination vaccine/toxoid), when no counseling is provided for beneficiaries ages 0 through 17, or with/without counseling for those age 18 and older. 
• 90472 - Immunization administration: includes percutaneous, intradermal, subcutaneous or intramuscular injections; each additional vaccine single and combination vaccine/toxoid. (List separately in addition to code for primary procedure.)
  • 90472 will only be used if another vaccine is given in addition to the COVID-19 vaccine. Providers may bill more than one unit of 90472 as appropriate.
    • 90460 - If counseling is provided for beneficiaries ages 0 through 17. 
• An EP modifier should be appended to all vaccine administration codes for NC Medicaid beneficiaries under age 21.
• A CG modifier should be appended to ALL COVID-19 vaccine AND administration claims submitted by a pharmacy participating in the immunization program.

As of Oct. 1, 2024, NC Medicaid ended coverage for CPT 99401 for COVID-19 vaccine counseling and added coverage of stand-alone vaccine counseling codes G0310, G0312 and G0315.

Providers should use codes G0310, G0312 and G0315 for vaccine counseling when the vaccine is not administered on the date of service. Please refer to Reminder: Key COVID-19 Changes Effective Oct. 1, 2024 and any related updates for coverage after Oct. 1, 2024.

Medicaid Medical Claims Billing for 340B COVID-19 Vaccines

• Providers shall bill their usual and customary charge for non-340B drugs.
• The Physician Administered Drug Program (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.
• The maximum reimbursement rate per unit is Wholesale Acquisition Cost (WAC) +3% and is NDC specific.

Table 1: ICD-10, CPT, and NDC codes for the 2026-2027 COVID-19 Vaccine Products*

*Please note 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 POS claims.

Medicaid Pharmacy Claims Billing for COVID-19 Vaccines

Effective Jan. 1, 2025, NC Medicaid will reimburse pharmacy providers for the administration and ingredient costs of COVID-19 vaccines at POS for beneficiaries ages 3 and older, in accordance with Center for Medicare & Medicaid Services (CMS) guidance. See Updated COVID-19 Reimbursement Policy.

Children ages 3 through 18 that qualify for the VFC Program may go to a pharmacy provider to receive their COVID-19 vaccine. Pharmacies must administer a non-VFC COVID-19 vaccine to qualify for reimbursement. Pharmacy providers authorized under the PREP Act declaration are eligible for Medicaid reimbursement for both the non-VFC COVID-19 vaccine and its administration. Pharmacy providers do not need to be enrolled as a VFC provider to qualify for reimbursement of a non-VFC COVID-19 vaccine.

Pharmacies are allowed to bill NC Medicaid Direct for vaccines on pharmacy claims at POS. Immunizing pharmacists are not required to submit vaccine administration claims on medical 837P or CMS 1500 form but remains an option for immunizing pharmacists who wish to do so. A CG modifier should be appended to ALL COVID-19 vaccine AND administration CPT codes submitted by a pharmacy participating in the immunization program.

Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are listed in Table 1.

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 COVID-19 vaccine claim submission guidance. 

• Alliance Health
• AmeriHealth Caritas North Carolina, Inc.
• Carolina Complete Health, Inc.
• Healthy Blue of North Carolina
• Trillium Health Resources
• United Health Care of North Carolina, Inc.
• Vaya Partners

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 to local health departments, Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC), hospitals and private providers.

For the 2026-2027 COVID-19 season, NCIP/VFC COVID-19 vaccines are available at no charge to providers for children ages 6 months through 18 who are eligible for the VFC program. The current NCIP coverage criteria and definitions of VFC categories can be found on DPH’s Immunization Branch webpage.

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 Medicaid beneficiaries through age18.

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 the 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. To determine who is eligible for NCIP COVID-19 and other vaccines, visit DPH’s Immunization Branch webpage.

Immunization Billing for Medicaid from FQHCs and RHCs

For beneficiaries ages 0 through 18

• If vaccines are provided through the NCIP/VFC, the center/clinic shall report the CPT vaccine codes (with $0.00 billed) under Physician Services NPI and may bill for the appropriate administration codes (e.g. see Reminder: Key COVID-19 Changes Effective Oct. 1, 2024). 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.

For beneficiaries ages 19 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 at 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 COVID-19 vaccine and administration fee rates, refer to the DHB's Physician Administered Drug Program (PADP) and Physician Services Fee Schedule.

Contact

• NCTracks Call Center:1-800-688-6696
• Prime Therapeutics, LLC: 1-844-620-6116
• NC Medicaid Managed Care health plans

Health Plan Pharmacy Lines

Standard Plan Pharmacy Lines

• AmeriHealth: 1-866-885-1406
• Healthy Blue: 1-833-434-1212
• Carolina Complete: 1-833-992-2785
• United Healthcare: 1-855-258-1593

Tailored Plan Pharmacy Lines 

• Alliance: 1-855-759-9300
• Trillium: 1-866-245-4954
• Vaya Partners: 1-800-540-6083