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COVID-19 Vaccines and Coverage

December 21, 2020

In the face of the COVID-19 pandemic, pharmaceutical companies have moved to produce vaccines. The Food and Drug Administration (FDA) awarded an Emergency Use Authorization (EUA) to two companies for their vaccines: Pfizer Learn more about third-party links on Dec. 11, 2020, and Moderna Learn more about third-party links on Dec. 18, 2020.

Federal and state health officials are working with the medical community to distribute the COVID-19 vaccine.

Rollout Projections: The federal government is working with drug companies to have 300 million doses Learn more about third-party links PDF Document by the end of January 2021. Health care workers and long-term care facility residents have priority access. The Centers for Disease Control and Prevention (CDC) projected rollout is below:

Phase

Access

Projected Start Date

1a

Health care workers

December 2020

1b

Long-term care facility residents via federal partnership with Walgreens and CVS

December 2020

2

Vaccinate broader population with the help of retail pharmacies

January 2021

3

Integrate vaccination into routine vaccine programs like influenza vaccine

Fall 2021

Initially, the federal government will pay for the vaccine. Blue Cross and Blue Shield of Oklahoma (BCBSOK), or self-funded groups, will cover administration of the vaccine as noted below:

Fully insured:

  • Vaccine and administration covered as a preventive service with no cost-share to members at in-network providers
  • Vaccine and administration covered with no cost-share to members if delivered at out-of-network providers through the end of the public health emergency

Self-funded employer groups:

  • Non-grandfathered self-funded employer groups - vaccine and administration covered as a preventive service with no cost-share to members at in-network providers
  • Vaccine and administration covered at no cost-share to members at out-of-network providers through the end of the public health emergency
  • Self-funded employer groups that don't cover preventive vaccines through their pharmacy benefit must cover the vaccine through their medical benefit
  • Grandfathered plans are not required to cover preventive services, including the COVID-19 vaccine

Medicare Advantage and Medicare Supplement

  • For 2020 and 2021, Medicare payment for the COVID-19 vaccine and its administration will be through the original fee-for-service Medicare program.
  • Submit claims for administering the COVID-19 vaccine to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved.
  • Members will have no cost-sharing on vaccines through Dec. 31, 2021.

Reimbursement:

  • In-network providers will be reimbursed for the administration fee based on contracted rates.
  • Out-of-network providers will be reimbursed based on established OON reimbursement policy that follows Medicare rates.

Balance billing: Providers are prohibited from billing patients for the vaccine or its administration, including balance billing, if the provider received the vaccine at no cost from the government.

Coding claims: CMS and the American Medical Association (AMA) have identified the codes to use in submitting claims. For more information, see CMS' guidance Learn more about third-party links.

Code

Use

Description

91300

Vaccine

Pfizer-Biontech Covid-19 Vaccine SARSCOV2 VAC 30MCG/0.3ML IM

0001A

Admin

Pfizer-Biontech Covid-19 Vaccine Administration – First Dose ADM SARSCOV2 30MCG/0.3ML 1ST

0002A

Admin

Pfizer-Biontech Covid-19 Vaccine Administration – Second Dose ADM SARSCOV2 30MCG/0.3ML 2ND

91301

Vaccine

Moderna Covid-19 Vaccine SARSCOV2 VAC 100MCG/0.5ML IM

0011A

Admin

Moderna Covid-19 Vaccine Administration – First Dose ADM SARSCOV2 100MCG/0.5ML1ST

0012A

Admin

Moderna Covid-19 Vaccine Administration – Second Dose ADM SARSCOV2 100MCG/0.5ML2ND

Dosage: Candidate vaccines may require one or two doses. The Pfizer and Moderna vaccines require two doses.

More information:

  • CDC COVID-19 Vaccination Program Interim Playbook Learn more about third-party links PDF Document for Jurisdiction Operations
  • Provider Relief Fund Learn more about third-party links – for reimbursement for administering the COVID-19 vaccine to the uninsured
  • CMS guidance Learn more about third-party links on Medicare billing for the COVid-19 vaccine administration

We continue to monitor information provided by the CDC and other government and health officials. We'll provide updates when we have them. For the latest information on COVID-19, we recommend visiting the CDC's COVID-19 website Learn more about third-party links.




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