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The purpose of this bulletin is to inform providers that DMAS and all managed care organizations (MCOs) will cover Pfizer-BioNTech COVID-19 vaccine doses for full benefit Medicaid and FAMIS members 5-11 years of age, consistent with the recently amended Federal Drug Administration’s (FDA) amended Emergency Use Authorization (EUA) for the Pfizer-BioNTech COVID-19 vaccine. Further contact information is included at the bottom of this document. For prior memos outlining DMAS COVID-19 vaccination coverage, please visit: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/MedicaidMemostoProviders. 

Consistent with the FDA’s amended EUA permitting administration of the Pfizer-BioNTech COVID-19 vaccine to individuals 5-11 years of age, the following COVID-19 vaccine administration codes will be covered for fee for service (FFS) and MCO members 5-11 years of age with dates of service on and after 10/29/2021, with FFS reimbursement rates listed below:

• 91307 ($0.01): 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, for intramuscular use
• 0071A ($40.00): 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; first dose
• 0072A ($40.00): 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; second dose

Administration of the Pfizer-BioNTech COVID-19 vaccine for members 5-11 years of age is covered under both the medical benefit, as outlined above, as well as the pharmacy benefit. Pharmacy providers should use Submission Clarification Code = 7 (medically necessary) to indicate the administration of a 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.

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

Prior authorization for COVID-19 vaccination is not required for FFS or MCO members. 

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

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