NC Medicaid Influenza Vaccine Guidelines for 2026-2027

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

This bulletin provides guidance on the 2026 – 2027 influenza season for NC Medicaid.

Vaccine strains for the 2026-2027 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’s (WHO) recommendations for the Northern Hemisphere 2026–2027 for influenza vaccine composition. For details on the 2026-2027 influenza vaccines, visit the Centers for Disease Control (CDC) Flu Season webpage.

Summary of NC Medicaid Influenza Vaccine Coverage:

• Fluarix, Flucelvax®, Flulaval™, and Fluzone®: NC Medicaid covers these products for beneficiaries age 6 months and older. These are available as medical or pharmacy point-of-sale (POS) claims.
• FluMist®: NC Medicaid covers Flumist® for beneficiaries age 2 through 49. It is available as medical or POS claim.
• Flublok®: NC Medicaid covers Flublok® for beneficiaries age 9 and older. It is available as medical or POS claim.
• Fluad®, Fluzone® HD: NC Medicaid covers these products for beneficiaries age 18 and older, when clinically appropriate. These are available as medical or POS claims.
• mFLUSIVA ®: NC Medicaid covers mFlusiva® for beneficiaries age 50 and older. It is available as medical or pharmacy POS claim.
• Vaccines for Children: Flu vaccines are part of the Vaccines for Children program (VFC) for beneficiaries age 18 and younger. Beneficiaries age 18 and younger may receive flu vaccines at a pharmacy outside of the VFC. 
• Pharmacy Age Restrictions: Pharmacies should refer to state law, federal law and individual immunization protocols for age limitations.

Medicaid Medical Claims Billing for Influenza Vaccines:

• The ICD-10-CM diagnosis code required for billing is: Z23 - Encounter for immunization.
• Providers are required to use appropriate National Drug Code (NDC) 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. Please refer to the table below.
  • Note: NDCs Change Each Year for Influenza 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 percutaneous, intradermal, subcutaneous, or intramuscular injections) one vaccine (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 influenza vaccine. Providers may bill more than one unit of 90472 as appropriate.
• 90460 - Immunization administration for beneficiaries through age 18 via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered.
• 90473 - Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid). Do not report 90473 in conjunction with 90471.
• 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 influenza vaccine AND administration claims submitted by a pharmacy participating in the immunization program.

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 webpage.

Medicaid Medical Claims Billing for 340B Flu 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 Influenza Vaccine Products

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

Medicaid Pharmacy Claims Billing for Influenza Vaccines:

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

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 this remains an option for immunizing pharmacists who wish to do so. Additional information can be found in the Medicaid bulletin, Vaccine Immunization Claims Can Be Submitted on Pharmacy Claims for NC Medicaid Direct Beneficiaries, published Nov. 28, 2022. A CG modifier should be appended to ALL influenza vaccine AND administration CPT codes submitted by a pharmacy participating in the immunization program.

Providers must bill 11-digit NDCs and appropriate NDC units. See table above for NDCs.

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. 

• 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 (NCIP/VFC

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 influenza season, NCIP/VFC influenza vaccines are available at no charge to providers for children ages six months through 18 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 DPH’s 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 Medicaid beneficiaries (through 18 years of age). 

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.

Billing VFC Influenza Vaccines for Medicaid Beneficiaries

If you have any questions or need assistance, please contact the Immunization Branch Help Desk at 1-877-873-6247 and press option 6.

Table 2: Influenza Billing Codes for Medicaid Beneficiaries ages19 and Under Who Receive VFC Influenza Vaccine

These codes are reported with $0.00.

*NDCs listed on Table 2 are NDCs of packs of syringes/vials as distributed by the DPH. For claims processing, providers should use the NDC listed on the actual syringe/vial used for administration as listed at the bottom of this bulletin.

Table 3: Administration Codes to Bill for VFC

* 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.

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 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 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 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.

Contact

• NCTracks Call Center – 1-800-688-6696
• Prime Therapeutics, LLC – 1-844-620-6116
• NC 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