New York State Medicaid Policy and Billing Guidance for Pharmacy Reimbursement of COVID-19 Oral Antivirals

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

Updated December 19, 2023
Updates are Highlighted

Paxlovid™
Medicaid members will obtain commercially available COVID-19 oral antiviral Paxlovid via NYRx. Prescribers or pharmacies may also choose to use the patient assistance program (PAP) PAXCESS to obtain Paxlovid at no cost: https://www.paxlovid.com/paxcess.

Lagevrio™
Prescribers or pharmacies must obtain commercially available COVID-19 oral antiviral Lagevrio™ via the patient assistance program (PAP) for members. Medicaid and Medicare enrollees must receive this product through the PAP operated by the manufacturer. For Lagevrio™, Merck has published program information https://www.merckhelps.com/LAGEVRIO.

IMPORTANT NOTES:

  • Pharmacy providers may not submit using 340B stock.
  • Pharmacy providers may continue to dispense the free United States Government (USG) distributed supply until stock depletion, using the existing guidance found here.
  • 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.
FFS 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:
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 the Dispensing Pharmacies NPI number*
461-EU (Prior Authorization Type Code) Enter "04" = Exempt Copay**

*If the drug is ordered by the prescriber & not the pharmacist, please enter the prescriber's NPI number
**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™ or Lagevrio™ (either face to face or via telehealth pursuant to NYS PHL Article 29-G and 18 NYCRR 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 consistent prescription history for the past 12 months.

Note: Telehealth can be utilized when prescribing Paxlovid™ or Lagevrio™. Services provided via telehealth will be reimbursed at the same rate noted in the chart above.

As described in the EUA, sufficient clinical information should be documented in the patient's profile when Lagevrio™ is prescribed or referred by a state-licensed pharmacist. Pharmacists prescribing Paxlovid™ or Lagevrio™ 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 patient at time of service,
  • if the member is a new or existing patient,
  • how COVID-19 test was performed,
  • confirmation of positive COVID-19 test,
  • 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 value of "09" [Healthcare Common Procedure Coding System (HCPCS)], 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) Leave field blank
*307-C7(Place of Service) Enter the value of "10" if prescribing for Telehealth Provided in Patient's Home

Enter value of "2" if prescribing for Telehealth Provided Other than in Patient's Home

*Include for services provided via telehealth only.

Please see the July 2020 issue of the Medicaid Update for further guidance on origin code and serial number values that must be submitted on the claim. In the origin code field use "5" and the corresponding serial number of "99999999" for "Pharmacy dispensing" when applicable for non-patient specific orders.

It is inappropriate practice to engage new or existing patients for the sole purpose of prescribing Paxlovid™ and Lagevrio™. 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