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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) Pfizer-BioNTech COVID-19 vaccine for members 6 months through 4 years of age,

 2) Moderna COVID-19 vaccine for members 6 months through 17 years of age, 3) Novavax vaccine for members at least 18 years of age. Corresponding COVID-19 vaccines will also be covered for 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 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 COVID-19 Vaccine for Children Ages 6 Months through 4 Years

In light of the Federal Drug Administration’s (FDA) amended Emergency Use Authorization (EUA) authorizing the Pfizer-BioNTech COVID-19 vaccine for individuals 6 months through 4 years of age, the following COVID-19 product and administration codes will be covered for corresponding fee for service (FFS) and MCO members with dates of service on and after 6/17/2022:

• 91308: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use
• 0081A: 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, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; first dose
• 0082A: 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, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; second dose
• 0083A: 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, 3 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; third dose

To be considered complete, the primary vaccine series for individuals aged 6 months through 4 years of age requires three doses of the Pfizer-BioNTeach vaccine for all individuals regardless of immune status.

Coverage of Moderna COVID-19 Vaccine for Children Ages 6 Months through 17 Years

In light of the Federal Drug Administration’s (FDA) amended Emergency Use Authorization (EUA) authorizing the Moderna COVID-19 vaccine for individuals 6 months through 5 years of age, 6 through 11 years of age and 12 through 17 years of age, all of 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 06/17/2022:

6 months through 5 years of age

• 91311:  Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 25 mcg/0.25 mL dosage, for intramuscular use
• 0111A: 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, 25 mcg/0.25 mL dosage; first dose
• 0112A: 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, 25 mcg/0.25 mL dosage; second dose
• 0113A: 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, 25 mcg/0.25 mL dosage; third dose

6 years through 11 years of age

• 91309*: Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, mRNALNP, spike protein, preservative free, 50 mcg/0.5 mL dosage, for intramuscular use
• 0091A: 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, 50 mcg/0.5 mL dosage; first dose, when administered to individuals ages 6 through 11
• 0092A: 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, 50 mcg/0.5 mL dosage; second dose, when administered to individuals ages 6 through 11
• 0093A: 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, 50 mcg/0.5 mL dosage; third dose, when administered to individuals ages 6 through 11

12 years through 17 years of age

• 91301*: 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, for intramuscular use
• 0011A*: Immunization administration by intramuscular injection of severe acute respiratory syndrome 0011A coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; first dose
• 0012A*: Immunization administration by intramuscular injection of severe acute respiratory syndrome 0012A coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; second dose
• 0013A*: Immunization administration by intramuscular injection of severe acute respiratory syndrome 0013A coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; third dose

* These codes have previously been covered for other adult populations but are now authorized for the aforementioned pediatric populations as of 6/17/2022.

The primary vaccine series for individuals aged 6 months through 17 years of age includes two doses of the Moderna vaccine for immunocompetent individuals, and a third dose at least one month later for individuals determined to have certain kinds of immunocompromise (see CDC guidance here).

Coverage of Novavax COVID-19 Vaccine for Adults at least 18 Years of Age

In light of the Federal Drug Administration’s (FDA) Emergency Use Authorization (EUA) of the Novavax COVID-19 vaccine for individuals 18 years of age and older, the following COVID-19 vaccine administration code will be covered for corresponding fee for service (FFS) and MCO members with dates of service on and after 7/13/2022:

• 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

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 associated vaccine products (i.e., 91304, 91308, 91311) that they receive for free. Of note, CMS continues to anticipate that, at this time, providers will not incur a cost for vaccine products.

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.

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