This bulletin applies to NC Medicaid Direct and NC Medicaid Managed Care.
The North Carolina General Assembly passed Session Law 2025-37 (HB 67), which gave authority to pharmacists to order and perform a Clinical Laboratory Improvement Amendments (CLIA)-waived influenza test and initiate treatment pursuant to the test result in accordance with Statewide Protocols.
Beginning Nov. 23, 2026, NC Medicaid will implement coverage of Test and Treat in Point of Sale (POS) Pharmacy for NC Medicaid-enrolled immunizing pharmacists ordering and performing a CLIA-waived influenza test. For more information on how to enroll with NC Medicaid as an immunizing pharmacist, please refer to the Immunizing Pharmacists Enrollment bulletin.
Billing and Reimbursement
- Claims for Influenza Test and Treat services will be processed through the POS Pharmacy claims system.
- Reimbursement rates for influenza tests are listed for the applicable NDCs (National Drug Codes) on the Pharmacy Point of Sale fee schedule. To review the fee schedule, please refer to the Fee Schedules posted on the NC Medicaid webpage. Select Pharmacy for the Program and Fee Schedule, then click apply filters to download the fee schedule.
- Pharmacies may bill for a clinical service administration fee of $32.50 plus the cost of the test in the Pharmacy Fee Schedule for eligible Test and Treat services.
- A $4 copayment applies, subject to the beneficiary's Medicaid eligibility and copayment requirements.
For NC Medicaid Direct:
Pharmacies must submit claims with a Level of Service (NCPDP Field 418-DI) value of 05 on the POS pharmacy claim to indicate it is for Test and Treat.
For NC Medicaid Managed Care:
Pharmacies must reach out to the individual managed care health plan to determine billing requirements.
Coverage Requirements
- Claims must be submitted only for Influenza Test and Treat services provided at the pharmacy and may not be used for take-home test kits.
- Only one Test and Treat service claim will be reimbursed per beneficiary per day.
- To receive reimbursement, pharmacies will need to ensure that the NDC for the influenza test is listed on the fee schedule.
- Pharmacies must maintain documentation of test results and make records available upon request for audit purposes.
- Test and Treat clinical services will only be paid to pharmacies located within the state of North Carolina.
- Border pharmacy providers (providers located within 40 miles of the North Carolina border) and other out-of-state pharmacy providers are not eligible for this clinical service.
By supporting Influenza Test and Treat services, NC Medicaid helps beneficiaries access timely testing and treatment in convenient, accessible settings while improving access to care through community pharmacies across North Carolina.
Contact
NC Medicaid Direct, 1-844-620-6116
Health Plan Pharmacy Lines
Standard Plan Pharmacy Lines
- AmeriHealth: 1-866-885-1406
- Healthy Blue: 1-833-434-1212
- Carolina Complete: 1-833-750-4461
- 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
Children and Families Specialty Plan
1-833-777-3788