Date: February 23, 2022
To: Enrolled Physicians and Pharmacies
Re: Billing Guidance -- Oral Antivirals for the Treatment of COVID-19
This notice informs providers that federally allocated oral antiviral treatment for COVID-19 is covered for Medicaid customers. The Illinois Department of Healthcare and Family Services (HFS) will reimburse Medicaid participating pharmacies the usual dispensing fee through National Council for Prescription Drug Programs (NCPDP) claim submission for all federally allocated COVID-19 oral antivirals.
There are two antiviral medications that have been issued Emergency Use Authorization (EUA) by the FDA: Pfizer's Paxlovid and Merck's Molnupiravir. Both treatments are in very limited supply, and a prescription does not guarantee the medication will be available.
An additional dispensing fee is not applicable for these drugs. The specific instructions below apply to Medicaid fee-for-service claims; however, the Medicaid HealthChoice Illinois managed care plans will also reimburse these claims through NCPDP claim submission.
Pharmacies may provide the service as per Illinois Department of Public Health guidelines and will be able to bill retroactively to dates of service beginning December 23, 2021, for the oral antiviral dose and dispensing via an electronic NCPDP claim according to the following instructions:
- Submit each treatment with the specific approved NDC for an eligible participant.
- Submit claim with a Basis of Cost Determination (423-DN) of "15" (Free product or no associated cost) with an associated Ingredient Cost Submitted (409-D9) value of $0.00.
- Quantity Dispensed (442-E7) should be submitted with the value that represents the quantity of drug product dispensed.
- Days Supply (405-D5) should be submitted with a value of "5".
- If a pharmacist is the prescriber, submit the NPI of the prescriber (pharmacist) in the Prescribing Practitioner (411-DB), submit a Submission Clarification Code (420-DK) of "42", and the Prescription Origin Code (419-DJ) would be "5" – Pharmacy
Questions regarding the fee-for-service program may be directed to a pharmacy billing consultant in the Bureau of Professional and Ancillary Services at 877-782-5565. Questions regarding coverage under managed care should be directed to the applicable managed care plan.
Kelly Cunningham, Administrator
Division of Medical Program