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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: Pfizer-BioNTech bivalent COVID-19 vaccine booster doses for members 6 months to 4 years of age at least 2 months after completion of primary vaccination with three doses of the monovalent (single strain) Pfizer-BioNTech COVID-19 vaccine.

This announcement expands on coverage previously authorized via a bulletin March 7, 2023 (here). Corresponding COVID-19 vaccines will 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 Pfizer-BioNTech bivalent COVID-19 vaccine booster dose for select members 6 months to 4 years of age:

In light of the Federal Drug Administration’s recently expanded Emergency Use Authorization of the Pfizer bivalent COVID-19 vaccine, the following COVID-19 vaccine product and administration codes will be covered to allow FFS and MCO members 6 months through 4 years of age, who received three monovalent Pfizer-BioNTech vaccine doses for their primary vaccination series, to receive a single bivalent vaccine booster dose at least 2 months after the completion of their primary vaccine series. This coverage will go into effect for bivalent booster vaccines administered to this population with dates of service on and after 3/14/2023:

• 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
• 0174A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, bivalent spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; booster dose

NOTE: 6 month to 4 year-old individuals who received a bivalent vaccine dose as part of their primary vaccination series, as previously authorized, are not eligible for an additional bivalent vaccine “booster dose” at this time.

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.

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.

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.