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Provider Notice Issued 08/08/2022

Date:    August 8, 2022           

To:       Enrolled Pharmacies          

Re:      Pharmacy COVID-19 Vaccination and Booster Update

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This notice provides updates for coverage of COVID-19 vaccinations and boosters. The Illinois Department of Healthcare and Family Services (HFS) reimburses Medicaid participating pharmacies an administration fee through National Council for Prescription Drug Programs (NCPDP) claim submission for all federally allocated COVID-19 vaccines.

All COVID-19 vaccines should be given in accordance with Centers for Disease Control (CDC) guidance.

Pediatric Booster Dose for Children Aged 5-11 Years with Pfizer BioNTech Vaccine
Effective with dates of service beginning, May 17, 2022, the Food and Drug Administration (FDA) approved children aged 5-11 years to receive a booster dose at least 5 months after a child's second vaccine dose.
 
Pediatric Vaccinations for Children Aged 6 Months through 4 Years with Pfizer BioNTech Vaccine
Effective with dates of service beginning June 17, 2022, the FDA lowered the initial age for children eligible to receive COVID-19 vaccination to 6 months.

The Pfizer BioNTech vaccine is available for children aged 6 months through 4 years. It is given in a 3-shot regimen. The initial 2 doses are administered 3 to 8 weeks apart followed by a third dose administered at least 8 weeks after the second dose.

Pediatric Vaccinations for Children Aged 6 Months through 5 Years with Moderna Vaccine
Effective with dates of service beginning June 17, 2022, the FDA lowered the initial age for children eligible to receive COVID-19 vaccination to 6 months.

The Moderna vaccine is available for children aged 6 months through 5 years. It is given in a 2-shot regimen, administered 4 to 8 weeks apart. A third primary series dose is authorized for administration at least 1 month following the second dose to children aged 6 months through 5 years with certain kinds of immunocompromise.

New Novavax Vaccination for Adults Aged 18 and Older
The Novavax vaccine is effective with dates of service beginning July 13, 2022. It is given in a 2-shot regimen, 3 to 8 weeks apart. Adults who are moderately or severely immunocompromised should receive 2 doses, given 3 weeks apart.

Note: Although the FDA has lowered the COVID-19 vaccination age for children, pharmacies are reminded that the December 23, 2020, Illinois Department of Financial and Professional Regulation (IDFPR) Emergency Powers Proclamation allows pharmacists to administer COVID-19 vaccinations only to children aged 3 years and older. Children under 3 should be referred to a primary care practitioner for COVID-19 vaccinations.

Billing Instructions:
The specific instructions below apply to Medicaid fee-for-service (FFS) claims, but the HealthChoice Illinois (HCI) Medicaid managed care organization (MCO) plans will also reimburse claims through NCPDP claim submission.   

  • Submit each vaccine with the specific approved vaccine NDC for an eligible participant.
  • Submit claim with a Basis of Cost Determination (423-DN) of "15" (Free product or no associated cost) with an associated Ingredient Cost Submitted (409-D9) value of $0.00.
  • Submit claim with the Professional Service Code (440-E5), populated with an "MA" (Medication Administered) to identify that the product was administered.
  • Quantity Dispensed (442-D7) should be submitted with the value that represents the quantity of drug product administered. 
  • Days Supply (405-D5) should be submitted with a value of "1".
  • Vaccines must be administered according to approved labeling for appropriate ages and dosing interval.

·         Submit the vaccine administration fee listed below in the Incentive Amount Submitted field (438-E3) on the same claim as the vaccine (i.e., ingredient).
 

NCPDP Codes and Allowed Amounts for COVID-19 Vaccine Administration

DoseSubmission Clarification Code
(420-DK)
Incentive Amount (Administration Fee 438-E3)Ingredient Cost
(409-D9)
Multi-Dose Vaccines  
First Dose02$42.14$0.00
Second Dose06$42.14$0.00
Booster Dose10$42.14$0.00

 

  • For multi-dose vaccines, submit 02 (other override) for the initial dose in the Submission Clarification Code (SCC) field.
  • For the second dose, submit 06 (the previous medication was a starter dose and now additional medication is needed to continue treatment) in the SCC field.
  • For the third dose, submit 10 (booster dose) in the SCC field.
  • Pharmacies must enter the National Provider Identifier (NPI) of the prescriber in the Prescribing Practitioner (411-DB). If the prescriber is the pharmacist, the NPI of the pharmacist may be submitted. If the pharmacy is using a pharmacist NPI, the pharmacy must submit an SCC of "42" and Prescription Origin Code (419-DJ)  "5 "– Pharmacy.

 
Pharmacy providers with questions regarding the Medicaid FFS program vaccine administration may call the Bureau of Professional and Ancillary Services at
877-782-5565. Pharmacies billing via NCPDP for HCI MCO plan members should contact the applicable plan for additional information.

 
Kelly Cunningham, Administrator
Division of Medical Programs



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Illinois Department of Healthcare and Family Services

JB Pritzker, Governor • Theresa Eagleson, Director




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