J1628 Medicaid reimbursement rate by state (2026)

• Order. States are listed from the highest published rate to the lowest. No single unit is shared by 8 or more states for J1628, so the order is by published amount and is not a like-for-like rank.
• Medicaid rate. The most the state's fee-for-service program pays for one unit, as published. 9 of the 34 states list more than one rate for J1628, by modifier, provider type or setting; the table shows the one that matches the provider level and setting used across states, without add-ons.
• Unit. Of the 34 states, 1 publish J1628 per unit and 1 per 1 mg, and 32 schedules print no unit at all (a flat amount per service).
• Per hour. J1628 is not billed in time units in these states, so no hourly figure is shown.
• Managed-care plans. The rule the state sets for its plans on this rate. What each rule means is explained below.
• % of Medicare. No Medicare physician fee schedule amount is on file for J1628, so there is no percentage.
• Source and date. Each Source link opens the state's own document; “since” is the date the rate took effect.

Published rates for J1628 run from $63.01 in Idaho to $145.66 in New Hampshire, a 2.3x gap in the same unit. Half the states pay more than the median of $67.00 and half pay less. The usual reasons for a spread like this in pharmacy rates:

• States differ in whether they pay a fixed fee, a percentage of a benchmark or invoice cost.
• Drugs given in a practice or clinic are commonly priced from a benchmark such as average sales price or wholesale acquisition cost, which moves every quarter.
• For children, many vaccines are supplied through the federal Vaccines for Children program, so the Medicaid payment can be for administration only.

Timing matters too. 29 states set the current rate for J1628 in 2026 or later. A state that has not updated its rate in years will drift down the ranking as others raise theirs.

What a plan pays for J1628 is negotiated privately, but the state decides how much room there is to negotiate. Here is how the rules break down across the 34 states.

In 5 states, the published rate binds plans: a floor, a pass-through or a state-set rate. In 16 states, plans negotiate and the published rate is a benchmark or out-of-network default. The rule for the remaining 13 states is not classified yet.

• Plans negotiate; the published rate applies out of network (16 states). In-network rates can be above or below the published rate. The published rate is the benchmark both sides know, and the fallback if no contract is signed.
• Plans must pay at least the published rate (4 states). The published rate is your floor. Negotiate up from it, and if a plan pays less, the contract provision is the basis for a payment dispute.
• The state sets the plan rate (1 state). There is little to negotiate on price. Contracting is about network participation, authorization and billing terms.

Plan-negotiated rates are never estimated here. To see the rule and its citation for a particular state, open that state's managed-care page, for example New Hampshire managed care.

J1628 is a HCPCS Level II drug code in the pharmacy line, billed mostly by practices and clinics that administer vaccines and drugs. J codes cover drugs that are not self-administered. One unit is the dose stated in the code, so a claim for a larger dose bills several units.

Many states require the National Drug Code (NDC) on the claim alongside the billing code. Drug codes are billed in units of the dose stated in the code, so a larger dose bills more units.

Before billing, confirm the rate, unit and any modifier with the state's current schedule or the plan: the amounts here are as published, not a guarantee of payment.