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The purpose of this bulletin is to inform providers:

• That DMAS fee-for-service (FFS) and all managed care organizations (MCOs) will cover the following for all full benefit Medicaid and FAMIS members: 1) Moderna bivalent COVID-19 vaccines for members 6 months – 17 years of age, 2) Pfizer-BioNTech bivalent COVID-19 vaccines for members 6 months – 11 years of age, 3) Novavax vaccine as booster doses for members 18 years of age and older.
• Of updated Clinical Laboratory Improvement Amendment (CLIA) requirements for select COVID-19 tests.

These announcements expand on coverage previously authorized via bulletins on October 5, 2022 (available for reference here) and April 21, 2021 (available for reference here), respectively. 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).

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 doses for members 6 months - 17 years of age:

In light of the Federal Drug Administration’s (FDA) expanded Emergency Use Authorization (EUA) of a Moderna bivalent COVID-19 vaccine for individuals 6 months to 5 years of age, the following COVID-19 vaccine product and administration codes will be covered for FFS and MCO members 6 months to 5 years of age, with dates of service on and after 12/8/2022:

• 91316: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 10 mcg/0.2 mL dosage, for intramuscular use
• 0164A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 10 mcg/0.2 mL dosage, booster dose

Providers should follow CDC guidance regarding eligibility and appropriateness of the authorized Moderna bivalent COVID-19 vaccine for use as a booster dose and/or as part of a primary vaccine series in this population.

In light of the Federal Drug Administration’s (FDA) expanded Emergency Use Authorization (EUA) of a Moderna bivalent COVID-19 vaccine as a booster dose for individuals 6-17 years of age, the following COVID-19 vaccine product and administration codes will be covered for FFS and MCO members 6-11 years of age, with dates of service on and after 10/12/2022:

• 91314: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage, for intramuscular use
• 0144A: 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, 25 mcg/0.25 mL dosage, booster dose

Additionally, the following COVID-19 vaccine product and administration codes will be covered for FFS and MCO members 12-17 years of age, with dates of service on and after 10/12/2022:

• 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

Note that billing codes 91313 and 0134A have previously been covered for members 18 years of age and older.

Coverage of Pfizer bivalent COVID-19 doses for members 6 months - 11 years of age:

In light of the Federal Drug Administration’s Emergency Use Authorization of a Pfizer bivalent COVID-19 vaccine for individuals 6 months to 4 years of age, the following COVID-19 vaccine product and administration codes will be covered for FFS and MCO members 6 months to 4 years of age with dates of service on and after 12/8/2022:

• 91317: Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use
• 0173A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, third dose

Providers should follow CDC guidance regarding eligibility and appropriateness of the authorized Pfizer bivalent COVID-19 vaccine for use as part of a primary vaccine series in this population.

In light of the Federal Drug Administration’s Emergency Use Authorization of a Pfizer bivalent COVID-19 vaccine as a booster dose for individuals 5-11 years of age, the following COVID-19 vaccine product and administration codes will be covered for FFS and MCO members 5 to 11 years of age with dates of service on and after 10/12/2022:

• 91315: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use
• 0154A: 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, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, booster dose

Coverage of Novavax COVID-19 booster dose for members 18 years of age and older:

In light of the Federal Drug Administration’s Emergency Use Authorization of a Novavax COVID-19 vaccine as a booster dose for individuals 18 years of age and older under certain circumstances as outlined by the CDC, the following COVID-19 vaccine product and administration codes will be covered for FFS and MCO members 18 years of age and older with dates of service on and after 10/19/2022:

• 91304: Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5 mL dosage
• 0044A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5 mL dosage; booster dose

Updated COVID-19 testing Clinical Laboratory Improvement Amendment (CLIA) requirements:

Currently covered COVID-19 multiplex laboratory testing codes are now eligible to be billed by laboratories meeting the CLIA accreditation status specified by CLIA, not exclusively those accredited as medium- and high-complexity laboratories, as previously specified in the April 21, 2021 Medicaid Bulletin “Updates to Coverage of COVID-19 Testing & Antibody Treatment.”

Service authorization is not required for FFS or MCO members for any of the codes for which coverage was announced 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, but are not limited to: 91304, 91313, 91314, 91315).

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.