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Elizabeth M. Whitehorn, Director

Provider Notice Issued 10/05/2022

Date:   October 5, 2022      

To:       Enrolled Pharmacies          

Re:      Pharmacy COVID-19 Booster Update

_______________________________________________________________________________________________________________________________________________________

This notice provides an update for coverage of new COVID-19 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.

The coverage update applies to claims for customers covered under traditional Medicaid fee-for-service (FFS) and the HealthChoice Illinois (HCI) managed care organization (MCO) plans. All COVID-19 vaccines should be given in accordance with Centers for Disease Control (CDC) guidance.

New Pfizer-BioNTech Booster Vaccine for Persons Aged 12 and Older
The Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product booster dose is available effective with dates of service beginning August 31, 2022, for persons aged 12 years and older.

New Moderna Booster Vaccine for Persons Aged 18 and Older
The Moderna COVID-19 Vaccine, Bivalent Product booster dose is available effective with dates of  service beginning August 31, 2022, for persons aged 18 years and older.

Per the CDC, the updated COVID-19 boosters add Omicron BA.4 and BA.5 spike protein components to the current vaccine composition, helping to restore protection that has waned since previous vaccination by targeting variants that are more transmissible and immune-evading.

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

Dose Submission Clarification Code
(420-DK)		 Incentive Amount (Administration Fee 438-E3) Ingredient Cost
(409-D9)
Multi-Dose Vaccines   ​  
First Dose 02 $42.14 $0.00
Second Dose 06 $42.14 $0.00
Booster Dose 10 $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