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The purpose of this bulletin is to inform providers that DMAS and all managed care organizations (MCOs) will cover the following for all full benefit Medicaid and FAMIS members: 1) a second vaccine booster dose of either the Pfizer-BioNTech or Moderna COVID-19 vaccines for adults, 2) a Pfizer-BioNTech COVID-19 vaccine booster for children ages 5-11 years of age, 3) the tris-sucrose formulation of Pfizer-BioNTech COVID-19 vaccine doses for adults, and 4) the new booster preparation of the Moderna COVID-19 vaccine. Vaccines should be administered according to the latest CDC Guidelines available here: CDC Vaccine Guidance. Further contact information is included at the bottom of this document. For prior memos outlining DMAS COVID-19 vaccination coverage, please visit: https://vamedicaid.dmas.virginia.gov/provider/library.  

Coverage of Second Vaccine Booster Doses of Pfizer-BioNTech or Moderna COVID-19 Vaccines

In light of the Federal Drug Administration’s (FDA) amended Emergency Use Authorization (EUA) of a second booster dose for older and certain immunocompromised individuals, claims for FDA-authorized Pfizer-BioNTech and Moderna COVID-19 vaccine booster product and administration codes will be covered for FFS and MCO members at least 50 years of age or at least 12 years of age with certain kinds of immunocompromise with dates of service on and after 03/29/2022. Eligible immunocompromised adults are those individuals who have undergone solid organ transplantation or who are living with conditions of an equivalent level of immunocompromise. Second boosters are covered when administered at least 4 months after a first booster dose.

Of note, individuals who received a Jansen primary vaccine series, who subsequently receive a Moderna booster, should receive a 100mcg dose of the Moderna vaccine as their initial booster, as per the FDA. In these situations, providers should bill for the 100mcg Moderna booster dose using the code for the product used, and the administration code corresponding to the concentration of the preparation used (e.g., 0094A with 91309; 0064A with 91301 or 91306).

See the following FDA guide for an overview of patient COVID-19 vaccine booster eligibility: https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/do-i-qualify-covid-19-vaccine-booster-and-which-one.

See the table at the bottom of this memo for a summary of FDA-authorized COVID-19 vaccine products covered for MCO and FFS members.

Coverage of Pfizer-BioNTech COVID-19 Vaccine Booster for Children Ages 5-11

In light of the Federal Drug Administration’s (FDA) amended Emergency Use Authorization (EUA) authorizing a booster dose of the Pfizer-BioNTech COVID-19 vaccines, the following COVID-19 administration code will be covered for fee for service (FFS) and MCO members with dates of service on and after 05/17/2022.

• 0074A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris- sucrose formulation; booster dose

Coverage of Tris-Sucrose Formulation of Pfizer-BioNTech COVID-19 Vaccine for Adults

In light of the Federal Drug Administration’s (FDA) amended Emergency Use Authorization (EUA) authorizing a tris-sucrose formulation of the Pfizer-BioNTech COVID-19 vaccine doses for adults, the following COVID-19 vaccine administration code will be covered for fee for service (FFS) and MCO members with dates of service on and after 01/3/2022.

• 91305: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use
• 0051A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; first dose
• 0052A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; second dose
• 0053A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; third dose
• 0054A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; booster dose

The new “gray cap” tris-sucrose formulation for adults is expected to largely replace the original “purple cap” (phosphate buffered saline [PBS)] formulation of the Pfizer-BioNTech vaccine. Indications for the third dose and booster doses of “gray cap” tris-sucrose formulations are the same as have been previously published for the original “purple cap” formulation. The original “purple cap” formulation will continue to be covered for FFS and MCO members.

Coverage of New Booster Preparation of the Moderna COVID-19 Vaccine

In light of the Federal Drug Administration’s (FDA) amended Emergency Use Authorization (EUA) of a new preparation of the Modern COVID-19 vaccine booster dose for adults, the following COVID-19 vaccine administration code will be covered for fee for service (FFS) and MCO members with dates of service on and after 03/29/2022.

• 91309: Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 50 mcg/0.5 mL dosage, for intramuscular use
• 0094A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 50 mcg/0.5 mL dosage, booster dose

The new “blue cap” preparation for adults is expected to largely replace the original “red cap” preparation of the Pfizer-BioNTech vaccine. Indications for the new “blue cap” preparation are the same as have been previously published for the original “red cap” preparation. The original “red cap” preparation will continue to be covered for FFS and MCO members.

Prior authorization is not required for FFS or MCO members for any of the codes included in this memo.

FFS reimbursement rates are available for reference via the DMAS fee file here.

Providers should not bill for associated vaccine products (i.e., 91305, 91307, 91309) if they received it for free. Of note, CMS continues to anticipate that, at this time, providers will not incur a cost for vaccine products.

Pharmacy providers should use Submission Clarification Code = 7 (medically necessary) to indicate the administration of a booster dose of COVID-19 vaccine for eligible FFS Members. Basis of Cost Determination ‘15’ (free product or no associated cost) and Professional Service Code ‘MA’ (Medication Administered) still apply. Any questions on FFS pharmacy claims processing may be directed to the Magellan pharmacy call center 7 days a week 24 hours per day at 800-932-6648. Any questions on MCO pharmacy claims processing may be directed to managed care points of contact summarized below.

An updated summary of COVID-19 vaccination codes covered for FFS and MCO full benefit Medicaid and FAMIS members, as well as Plan First members until the last day of the first calendar quarter in the year after the end of the federal public health emergency, is included below:

DMAS Covered COVID-19 Vaccination Codes

For questions on coverage for members enrolled in a managed care organization, refer to the contact information listed below.

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