New York State (NYS) Medicaid Policy and Billing Guidance for Reimbursement of COVID-19 Therapeutics Dispensing or Administration at Pharmacies

As of 3/24/2023 Updates are highlighted

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

Effective September 14, 2021, NYS Medicaid will reimburse pharmacies for the administration or dispensing of COVID-19 therapeutics, including monoclonal antibodies (mAb), with no member cost sharing. The Ninth amendment to the Public Readiness and Emergency Preparedness Act (PREP Act) expands the scope of authority for licensed pharmacists to order and administer certain COVID-19 therapeutics to populations authorized by the Food and Drug Administration (FDA). This policy applies to both Medicaid fee for service (FFS) and Medicaid Managed Care (MMC) to include mainstream MMC plans, HIV Special Needs Plans (HIV SNPs), and Health and Recovery Plans (HARPs).

NYS Medicaid Policy for Coverage:
  • The NYS Medicaid program will reimburse NYS Medicaid enrolled pharmacies for the administration and dispensing of COVID-19 therapeutics.
  • A pharmacy will only be reimbursed for a dispensing fee if a COVID-19 therapeutic is dispensed, but not administered.
  • A pharmacy will be reimbursed a dispensing fee and an administration fee if a COVID-19 therapeutic is dispensed and administered.
  • The COVID-19 therapeutic must be approved or granted Emergency Use Authorization (EUA) through the FDA, and must be ordered and administered in accordance with the FDA approval or authorization.
  • Pharmacists must adhere to guidance in the PREP Act, for further information see the following: Fact Sheet Expanding Access to Therapeutics COVID-19 HHS PREP ACT Declaration: 9th Amendment.
  • Prior authorization is not required.
  • Providers are prohibited from charging Medicaid members a co-payment or any cost-sharing responsibility for COVID-19 therapeutics, consistent with other COVID-19 Medicaid guidance.
NYS FFS Pharmacy Billing for COVID-19 mAb Dispensing or Dispensing and Administration:
  • The following billing instructions and fees apply to the Medicaid FFS program. To bill for the dispensing of the COVID-19 mAb, the pharmacy must submit a valid NDC. NDCs are listed in the Emergency Use Authorization for each COVID-19 mAb. Additionally, providers can also perform a search for each NDC using the eMedNY formulary search page.
  • Pharmacies must bill with a cost of $10.09 and will be reimbursed a $10.08 dispensing fee.
  • Pharmacies must bill the appropriate quantity and a day supply per package labeling if the COVID-19 mAb is being dispensed.
  • Pharmacies that are also billing for the administration of the COVID-19 mAb must submit a separate claim with the appropriate administration code. To do this, the claim segment field 436-E1 (Product/Service ID Qualifier) must contain a value of "09" (HCPCS). This qualifies the code submitted in field 407-D7 (Product/Service ID) as a procedure code. In field 407- D7 (Product/Service ID), enter the procedure code from Table 2 below for the appropriate product administrated.
  • Bill with a quantity of "1" and a day supply of "1" for administration.
  • If the pharmacist is ordering the COVID-19 mAb therapeutic, Field 411-DB (Prescriber ID) is left blank. If a prescriber has ordered the COVID-19 mAb therapeutic, add the NPI of the prescriber in this field.
Table 1 - Billing Instructions
NCPDP D.0. Claim Segment Field Value
436-E1 (Product/Service ID Qualifier) Enter a value of "03" (NDC) or "09" (HCPCS), which qualifies the code
407-D7 (Product/Service ID) Enter one applicable Procedure Code from Table 2
444-E9 (Pharmacist ID) Enter Pharmacist National Provider Identifier (NPI) number
411-DB (Prescriber ID) Enter Prescriber National Provider Identifier (NPI) number **
461-EU (Prior Authorization Type Code) Enter 04= Exempt Copay***

Please see the July 2020 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.
** Leave the field blank if the pharmacist is ordering the COVID-19 therapeutic. For Evusheld, the NPI of the prescriber must be on the claim.
*** Claims submitted for COVID-19 related testing, evaluation, and treatment that do not adjudicate with a zero copayment can be systematically adjusted by utilizing 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

Table 2 - Payment Allowances and Effective Dates for COVID-19 mAb for subcutaneous administration*
Code Labeler Name Procedure Name Payment Allowances Effective Date Termination Date**
M0240 Regeneron Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring, subsequent repeat doses $309.60 9/14/2021 1/24/2022
M0243 Regeneron Intravenous infusion or subcutaneous injection casirivimab and imdevimab, includes infusion and post administration monitoring $309.60 9/14/2021 1/24/2022
M0241 Regeneron Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence – subsequent repeat doses $525.00 9/14/2021 1/24/2022
M0244 Regeneron Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence – 1st dose $525.00 9/14/2021 1/24/2022
M0220 AstraZeneca Injection, tixagevimab and cilgavimab, for the pre- exposure prophylaxis only,includes injection and post administration monitoring $105.35 12/8/2021 1/26/2023*
M0221 AstraZeneca Injection, tixagevimab and cilgavimab, for the pre- exposure prophylaxis only, includes injection and post administration monitoring in the home or residence $175.35 12/8/2021 1/26/2023*

*As other Monoclonal Antibody (mAb) Therapeutics become available this table will be updated.
**No longer athorized by the FDA.

Medicaid Managed Care (MMC) Billing

The COVID-19 mAb and oral therapeutic billing guidance and reimbursement amounts are specific to Medicaid FFS. Individual MMC plans should be contacted for reimbursement and billing guidance for pharmacy claims with a date of service before April 1, 2023. Plan information can be found by visiting the following website: Medicaid Managed Care Pharmacy Benefit Information Center.

Additional Information