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The purpose of this bulletin is to inform providers that DMAS fee-for-service and all managed care organizations (MCOs) will cover the following for all full benefit Medicaid and FAMIS members: 1) Moderna bivalent COVID-19 vaccines as booster doses for members 18 years of age and older, 2) Pfizer-BioNTech bivalent COVID-19 vaccines as booster doses for members 12 years of age and older, and 3) the Novavax vaccine for members 12 years of age and older. Corresponding COVID-19 vaccines will also be covered for age-appropriate Plan First members until the last day of the first calendar quarter that begins one year after the last day of the federally declared public health emergency (PHE). DMAS will no longer cover monovalent boosters for Moderna and Pfizer-BioNTech vaccines for members 12 years of age and older. Expanded coverage of the Novavax vaccine builds on coverage previously authorized for adults at least 18 years of age via a July 27, 2022 bulletin (available for reference here).

Vaccines should be administered according to the latest CDC Guidelines available here: CDC Vaccine Guidance. Further DMAS and MCO 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 Moderna bivalent COVID-19 booster doses for members 18 years of age and older

In light of the Federal Drug Administration’s (FDA) Emergency Use Authorization (EUA) of a Moderna bivalent COVID-19 vaccine as a booster dose for individuals 18 years of age and older, the following COVID-19 vaccine product and administration codes will be covered for corresponding fee for service (FFS) and MCO members with dates of service on and after 8/31/2022:

• 91313: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 50 mcg/0.5 mL dosage, for intramuscular use
• 0134A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 50 mcg/0.5 mL dosage, booster dose

In conjunction with the aforementioned EUA, the following codes for monovalent booster doses of the Moderna COVID-19 vaccine for individuals 18 years of age and older will no longer be covered for claims with dates of service after 8/31/2022: 0064A, 0094A.

Coverage of Pfizer-BioNTech bivalent COVID-19 booster doses for members 12 years of age and older

In light of the Federal Drug Administration’s (FDA) Emergency Use Authorization (EUA) of a Pfizer-BioNTech bivalent COVID-19 vaccine as a booster dose for individuals 12 years of age and older, the following COVID-19 vaccine product and administration codes will be covered for corresponding fee for service (FFS) and MCO members with dates of service on and after 8/31/2022:

• 91312: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use
• 0124A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation, booster dose

In conjunction with the aforementioned EUA, the following codes for monovalent booster doses of the Pfizer-BioNTech COVID-19 vaccine for individuals 18 years of age and older will no longer be covered for claims with dates of service after 8/31/2022: 0004A, 0054A.

Expanded coverage of the Novavax vaccine for members 12 years of age and older

In light of the Federal Drug Administration’s (FDA) Emergency Use Authorization (EUA) of the Novavax COVID-19 vaccine for individuals 12 to 17 years of age, the following COVID-19 vaccine product and administration codes will be covered for corresponding fee for service (FFS) and MCO members with dates of service on and after 8/22/2022:

• 91304: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage, for intramuscular use
• 0041A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage; first dose
• 0042A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage; second dose

Note that the Novavax product and administration codes covered for the 12 to 17 year-old population are the same as those previously announced for adults 18 years of age and older.

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 vaccine products if they receive the doses for free (these may include 91313, 91314, 91312, 91315, 91304).

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.

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