Coverage of Pfizer COVID-19 Vaccine Administration Booster
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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 booster doses for full benefit Medicaid and FAMIS members consistent with the recently amended FDA EUA for the Pfizer-BioNTech COVID-19 vaccine. In accordance with the American Rescue Plan Act of 2021 (ARPA), this coverage will be extended to Plan First members “until the last day of the first calendar quarter that begins one year after the end of the federal public health emergency.” 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.
In light of the Federal Drug Administration’s (FDA) amended Emergency Use Authorization (EUA) authorizing administration of a booster dose of the Pfizer-BioNTech COVID-19 vaccine, 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 9/22/2021, with FFS reimbursement rates listed below:
- 0004A ($40.00): 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, diluent reconstituted; booster dose
Eligible individuals are those who have completed the primary vaccine series at least 6 months ago AND are specified in the FDA Pfizer-BioNTech EUA amendment (see newsroom link here: https://www.fda.gov/news-events/fda-newsroom/press-announcements), namely:
- individuals 65 years of age and older; OR
- individuals 18 through 64 years of age at high risk of severe COVID-19; OR
- individuals 18 through 64 years of age whose frequent institutional or occupational exposure to SARS-CoV-2 puts them at high risk of serious complications of COVID-19 including severe COVID-19
Of note, this booster dose is not the same as the third dose authorized for certain immunocompromised patients.
Prior authorization is not required for either FFS or MCO members.
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 the covered CPT and HCPCS codes currently available for COVID-19 vaccination for full benefit Medicaid and FAMIS populations indefinitely (including FFS and MCO members), as well as Plan First members until the last day of the first calendar quarter that begins one year after the end of the federal public health emergency, is included below:
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CPT Code |
Description |
Reimbursement Rate |
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91300
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Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use |
$0.01 |
|
0001A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose |
$40.00 |
|
0002A |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose |
$40.00 |
|
0003A |
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, diluent reconstituted; third dose |
$40.00 |
|
0004A |
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, diluent reconstituted; booster dose |
$40.00 |
|
91301 |
Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use |
$0.01 |
|
0011A |
Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose |
$40.00 |
|
0012A |
Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; second dose |
$40.00 |
|
0013A |
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, 100 mcg/0.5 mL dosage; third dose |
$40.00 |
|
91303 |
SARSCOV2 VAC AD26 .5ML Janssen Covid-19 Vaccine |
$0.01 |
|
0031A |
ADM SARSCOV2 VAC AD26 .5ML Janssen Covid-19 Vaccine Admin. |
$40.00 |
CMS continues to anticipate that, at this time, providers will not incur a cost for vaccine products (CPT 91300, 91301, 91303). Providers should not bill for vaccine products if they received it for free.
For questions on coverage for members enrolled in a managed care organization, refer to the contact information listed below.
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PROVIDER CONTACT INFORMATION & RESOURCES |
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Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. |
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Medicall (Audio Response System) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. |
1-800-884-9730 or 1-800-772-9996 |
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KEPRO Service authorization information for fee-for-service members.
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Provider Appeals DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal. |
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Managed Care Programs Medallion 4.0, Commonwealth Coordinated Care Plus (CCC Plus), and Program of All-Inclusive Care for the Elderly (PACE). In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider. The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals. |
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Medallion 4.0 |
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CCC Plus |
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PACE |
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Magellan Behavioral Health Behavioral Health Services Administrator, check eligibility, claim status, service limits, and service authorizations for fee-for-service members. |
www.MagellanHealth.com/Provider For credentialing and behavioral health service information, visit: www.magellanofvirginia.com, email: VAProviderQuestions@MagellanHealth.com,or Call: 1-800-424-4046 |
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Provider HELPLINE Monday–Friday 8:00 a.m.-5:00 p.m. For provider use only, have Medicaid Provider ID Number available. |
1-804-786-6273 1-800-552-8627 |
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Aetna Better Health of Virginia |
www.aetnabetterhealth.com/Virginia 1-800-279-1878 |
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Anthem HealthKeepers Plus |
1-800-901-0020 |
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Magellan Complete Care of Virginia |
1-800-424-4518 (TTY 711) or 1-800-643-2273 |
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Optima Family Care |
1-800-881-2166 www.optimahealth.com/medicaid |
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United Healthcare |
and www.myuhc.com/communityplan 1-844-752-9434, TTY 711 |
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Virginia Premier |
1-800-727-7536 (TTY: 711), www.virginiapremier.com |