Attention: Pharmacists who administer vaccines Zoster Vaccine Recombinant, Adjuvanted, Suspension for Intramuscular Injection (Shingrix) CPT code 90750: Billing Guidelines

Effective with date of service November 8, 2017, the North Carolina Medicaid Program covers claims for pharmacist administration of Zoster Vaccine Recombinant, Adjuvanted, Suspension for Intramuscular Injection (Shingrix) for use in the Physician's Drug Program with CPT code 90750 - Zoster (shingles) vaccine, (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection.

The suspension for injection is supplied as a single-dose vial of lyophilized varicella zoster virus glycoprotein E (gE) antigen component to be reconstituted with the accompanying vial of AS01B adjuvant suspension component. After reconstitution, a single dose of Shingrix is 0.5 mL. Shingrix is indicated for prevention of herpes zoster (shingles) in adults aged 50 years and older. Shingrix is NOT indicated for prevention of primary varicella infection (chickenpox).

The recommended dose of Shingrix is two doses (0.5 mL each) administered intramuscularly according to the following schedule: A first dose at month 0 followed by a second dose administered anytime between 2 and 6 months later. See prescribing information for details.

For Medicaid Billing:

  • The ICD-10-CM diagnosis code required for billing is: Z23 - Encounter for immunization
  • Providers must bill with CPT code: 90750 - Zoster (shingles) vaccine, (HZV), recombinant, sub-unit, adjuvanted, for intramuscular injection. Pharmacists will also need to append a CG modifier to both vaccine and administration CPT codes.
  • One Medicaid unit of coverage is: 0.5 mL
  • The maximum reimbursement rate per unit is: $144.20
  • Providers must bill 11-digit National Drug Codes (NDCs) and appropriate NDC units. The NDCs are: 58160-0823-11 and 58160-0819-12
  • The NDC units should be reported as "UN1".
  • For additional information, refer to the January 2012, Special Bulletin, National Drug Code Implementation Update.
  • For additional information regarding NDC claim requirements related to the PDP, refer to the PDP Clinical Coverage Policy No. 1B, Attachment A, H.7 on DMA's website.
  • Providers shall bill their usual and customary charge for non-340B drugs.
  • PDP reimburses for drugs billed for Medicaid and NCHC beneficiaries by 340B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340B drugs shall bill the cost that is reflective of their acquisition cost. Providers shall indicate that a drug was purchased under a 340B purchasing agreement by appending the "UD" modifier on the drug detail.
  • The fee schedule for the Physician's Drug Program is available on DMA's PDP web page .