New York State Medicaid Coverage Policy and Billing Guidance for the 2023-2024 COVID-19 Vaccines

  • Guidance is also available in Portable Document Format (PDF)

This guidance has been updated February 20, 2024, and supersedes previously published coverage guidance for COVID-19 oral antivirals.
Updates are highlighted below.

Paxlovid™
Medicaid members will obtain commercially supplied, New Drug Application (NDA)-labeled Paxlovid™ via NYRx. Prescribers or pharmacies may also choose to use the patient assistance program (PAP) PAXCESS to obtain Paxlovid™ at no cost.
Paxlovid™ that has been authorized and labeled for Emergency Use Authorization (EUA) and previously distributed by the U.S. Government (USG) will be authorized for claim submissions through March 8, 2024. Providers may not bill the NDC, nor be reimbursed a dispensing fee, for EUA-labeled Paxlovid™ after this date. As a United States Food and Drug Administration (FDA) approved drug for the treatment of COVID-19, NYRx recognizes Paxlovid™, either as the EUA or NDA labeled product, as first line treatment.

Lagevrio™
Medicaid members may obtain commercially supplied Lagevrio™ via NYRx. Lagevrio™ could be prescribed as second-line treatment for Medicaid members when Paxlovid™ is clinically inappropriate.

IMPORTANT NOTES:

  • Pharmacy providers may not submit using 340B stock.
  • Pharmacy providers may continue to dispense the free USG-distributed supply until stock depletion, or until an authorization or approval for the drug is no longer in effect.
  • Pharmacies may not label or submit a claim for USG-distributed products as commercially available products. (NY Education Law Article 137 Section 6815(2)).

Coverage Policy:

  • Prior authorization is not required.
  • Providers are prohibited from charging Medicaid members a co-payment or any cost-sharing responsibility for COVID-19 oral antivirals, consistent with other COVID-19 Medicaid guidance.

NYRx Pharmacy Billing:

  • To bill for the commercial COVID-19 oral antivirals, the pharmacy must submit a valid National Drug Code (NDC). Providers can perform a search for each NDC using the eMedNY formulary search page.
  • Pharmacies must bill the actual acquisition cost of the commercial product and will be reimbursed for the drug and a $10.18 dispensing fee.
  • To bill for the evaluation and management associated with the prescribing of Paxlovid™, pharmacies will submit using the National Council for Prescription Drug Programs (NCPDP) D.0 claim format and enter one of the Healthcare Common Procedure Coding System (HCPCS) codes identified below.

Billing Instructions for COVID-19 oral antivirals:

NCPDP D.0. Claim Segment Field Value
436-E1 (Product/Service ID Qualifier) Enter a value of "03" (NDC)
444-E9 (Pharmacist ID) Enter Pharmacist National Provider Identifier (NPI) number
411-DB (Prescriber ID) Enter Prescriber NPI number*
461-EU (Prior Authorization Type Code) Enter "04" = Exempt Copay**

*If the drug is ordered by a state-licensed pharmacist, please enter the pharmacy’s NPI.
**Claims submitted for COVID-19 related testing, evaluation, and treatment that do not adjudicate with a zero copayment can be systematically adjusted by utilizing the National Council for Prescription Drug Programs (NCPDP) field. This instruction can be found in the NCPDP D.0 Companion Guide, located on the eMedNY "5010/D.0 Transaction Instructions" web page.

Billing Instructions for Evaluation and Management related to Pharmacist Prescribing:
A state-licensed pharmacist prescribing Paxlovid™ (either face to face or via telehealth pursuant to NYS PHL Article 29-G and 18 NYCRR Section 538.1 (c)(4)) may enter one of the following HCPCS codes when performing evaluation and management of an enrollee:

HCPCS Code Value Fee
99605* Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; 15 minutes, new patient. $48.20
99606** Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; 15 minutes, established patient. $15.29

*If the pharmacist cannot prescribe and must refer due to reasons described in the EUA, the HCPCS code "99605" may be submitted as a result of the referral.
**A patient would be considered established if they have a consistent prescription history for the past 12 months.

As described in the EUA, sufficient clinical information should be documented in the patient's profile when Paxlovid™ is prescribed or referred by a state-licensed pharmacist. Pharmacists prescribing Paxlovid™ either face to face or via telehealth must retain documentation that includes:

  • Member consent - either written (face to face) or notated (telehealth),
  • Modality of service - face-to-face or telephonic,
  • date, time, and duration of the encounter,
  • location of the patient at the time of service,
  • if the member is a new or existing patient,
  • the result of the clinical decision, and
  • the corresponding prescription number.

The above HCPCS codes may be submitted in the NCPDP D.0 format, as outlined below.

NCPDP D.0 Claim Segment Field Value
436-E1 (Product/Service ID Qualifier) Enter the applicable value, which qualifies the code submitted in field 407-D7 (Product/Service ID) as a procedure code
407-D7 (Product/Service ID) Enter the value of "99605" if prescribing for a new patient
Enter the value of "99606" if prescribing for an established patient
444-E9 (Pharmacist ID) Enter Pharmacist National Provider Identifier (NPI) number
411-DB (Prescriber ID) Enter the Pharmacy's NPI number
*307-C7(Place of Service) Enter value of "2" if prescribing for Telehealth Provided Other than in Patient's Home
Enter the value of "10" if prescribing for Telehealth Provided in Patient's Home

*Include for services provided via telehealth only.
Please see the NYS Medicaid Pharmacy Manual Policy Guidelines document for further guidance on origin code and serial number values that must be submitted on the claim.

It is inappropriate practice to engage new or existing patients for the sole purpose of prescribing Paxlovid™ without cause. Providers may only submit claims for payment for services actually furnished and which were medically necessary (18 NYCRR 504.3(e)). All claims are subject to audit and recovery.

Questions and Additional Information