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)
As of November 8, 2022 - Updates are Highlighted

Effective December 29, 2021, New York State (NYS) Medicaid will reimburse pharmacies for dispensing Coronavirus Disease 2019 (COVID-19) oral antivirals with no member cost-sharing. 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).

Effective July 6, 2022, NYS will reimburse pharmacies for clinical decision making associated with the prescribing of Paxlovid™ (nirmatrelvir and ritonavir).

Coverage Policy:
  • COVID-19 oral antivirals must be approved or granted Emergency Use Authorization (EUA) through the FDA and must be ordered in accordance with the FDA approval or authorization.
  • Paxlovid™ (nirmatrelvir and ritonavir) must be prescribed for an individual patient by a physician, nurse practitioner, or physician assistant authorized under NYS law to prescribe oral antivirals, or a state-licensed pharmacist in accordance with the EUA for Paxlovid™.
  • Lagevrio™ (molnupiravir) must be prescribed for an individual patient by a physician, nurse practitioner (NP), or physician assistant (PA) authorized under NYS law to prescribe oral antivirals.
  • 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 dispensing of COVID-19 oral antivirals, the pharmacy must submit a valid National Drug Code (NDC). NDCs are listed in the Emergency Use Authorization for each COVID-19 oral antiviral. Additionally, providers can also perform a search for each NDC using the eMedNY formulary search page.
  • Pharmacies must bill with a cost of $10.19 and will be reimbursed 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 Prescriber NPI number*
461-EU (Prior Authorization Type Code) Enter "04" = Exempt Copay**

*Leave the field blank if the pharmacist is ordering the COVID-19 therapeutic.
**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 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 PaxlovidTM. Services provided via telehealth will be reimbursed at the same rate noted in the chart above.

Sufficient clinical information as described in the EUA 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 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.

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.

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.

MMC Pharmacy Billing:

The COVID-19 oral antivirals' billing guidance and reimbursement amounts are specific to Medicaid FFS. Individual MMC plans should be contacted for their specific reimbursement and billing guidance. Plan information can be found by visiting the following website: Medicaid Managed Care Pharmacy Benefit Information Center.

Additional Information:
Questions:
  • For Medicaid FFS billing questions, please contact the eMedNY Call Center at (800) 343-9000.
  • For Medicaid FFS Pharmacy Policy questions, please contact: ppno@health.ny.gov.