Effective June 18, 2022, North Carolina Medicaid and NC Health Choice will cover the administration of the primary series of the Pfizer-BioNTech COVID-19 pediatric vaccine for administration to children ages 6 months to under 5 years.
The Pfizer-BioNTech COVID-19 Vaccine is a preservative-free suspension for injection in a multiple dose vial. It is administered intramuscularly as a single dose (0.2 mL). See full prescribing information for further detail.
The Pfizer-BioNTech COVID-19 Vaccine is administered as a primary series of three doses in which the initial two doses are administered three weeks apart followed by a third dose administered at least eight weeks after the second dose in individuals ages 6 months to under 5 years.
Code for Pfizer-BioNTech COVID-19 Pediatric Vaccine Primary Series (children ages 6 months to under 5 years)
- 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 - Second dose
- 0083A - Third dose
Pharmacy providers are ONLY able to vaccinate children ages 3 years and older per the criteria set forth by the Federal Emergency PREP Act.
For Medicaid and NC Health Choice Billing
- The ICD-10-CM diagnosis code required for billing is: Z23 - Encounter for immunization
- Providers must bill with CPT code: 91308
- One Medicaid and NC Health Choice unit of coverage is: 0.2 mL (one dose)
- The maximum reimbursement rate per unit is: N/A (federally supplied)
- Providers must bill 11-digit NDCs and appropriate NDC units. The NDCs are: 59267-0078-01, 59267-0078-04
- The NDC units should be reported as "UN1"
- The fee schedule for the PADP is available on NC Medicaid's PADP web page
Important Claims Information
- NC Medicaid and NC Health Choice will reimburse at the Medicare-approved COVID-19 vaccination administration rate of $65.
- Claims must have appropriate NDCs that correspond to the vaccine used for administration and corresponding CPT code.
- Claims must contain both administration codes and vaccine codes to pay (e.g., 0081A, 0082A, or 0083A for corresponding administration code for first and second pediatric vaccine, respectively).
- Vaccine codes should be reported as $0.00.
- NC Medicaid and NC Health Choice do not allow copays to be charged for COVID-19 immunization or administrations.
- COVID-19 vaccines are exempt from the Vaccines For Children (VFC) program.
- Pharmacies may administer Pfizer Pediatric COVID-19 Vaccines to any Medicaid beneficiary (ages 3 years and older) and NC Health Choice beneficiary (ages 6 through 11 years) [in general, during the pandemic, pharmacies have been given authorization to administer any COVID-19 vaccine as per FDA/EUA age approval to Medicaid and/or NC Health Choice beneficiary]. All other vaccines (non-COVID-19 vaccines), that are approved by the NC Board of Pharmacy to be administered by a pharmacist, are only permissible to be administered at a pharmacy for NC Medicaid beneficiaries age 19 and older.
- TJ modifier should be appended to all NC Health Choice claims (through age 18).
- EP modifier should be appended to all non-NC Health Choice (only NC Medicaid beneficiaries) younger than age 21.
- CG modifier should be appended to ALL COVID-19 vaccine AND administration claims submitted by a pharmacy participating in the immunization program.
- See NC Health Directors Standing Order for more information.
CONTACT
NCTracks Contact Center: 800-688-6696