SPECIAL BULLETIN COVID-19 #256: Moderna Pediatric Vaccine Primary Series for Children Ages 6 Months Through 5 Years

Effective June 18, 2022, NC Medicaid and NC Health Choice will cover the administration of the primary series of the Moderna COVID-19 pediatric vaccine for administration to children ages 6 months through 5 years. 

Moderna COVID-19 Vaccine is a preservative-free suspension for injection in a multiple dose vial. It is administered intramuscularly as a single dose (0.25 mL). See full prescribing information for further detail.

The Moderna COVID-19 Vaccine is administered as a primary series of two doses administered four to eight weeks apart. Immunocompromised patients can receive a third dose four weeks after the primary series.

Code for Moderna COVID-19 Pediatric Vaccine Primary Series (children ages 6 months through 5 years)

  • 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

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: 91311
  • One Medicaid and NC Health Choice unit of coverage is: 0.25 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: 80777-0279-05, 80777-0279-99
  • 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 at $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
  • 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 Moderna PEDIATRIC COVID-19 Vaccines to any NC Medicaid beneficiary (ages 3 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 Medicaid beneficiaries age 19 and older. 
  • EP modifier should be appended to all non-NC Health Choice (only 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 Director’s Standing Order for more information.

Information on Booster Dose for Moderna

Ages 6 months through 5 years non-immunocompromised:

  • Age 5 years and older should receive a single booster dose of Pfizer-BioNTech at least five months following completion of the primary series (two doses Moderna, or three doses Pfizer)
  • A booster dose is not recommended for ages 6 months through 4 years.

Ages 6 months through 5 years Primary Three-Dose Series for Immunocompromised:

  • Dose one and two should be four weeks apart
  • Dose two and three should be at least four weeks apart
  • Can use administration code 0112A for Doses two and three
  • Ages 5 years and older should receive a single booster dose of Pfizer-BioNTech at least three months following completion of the three-dose primary series.
  • A booster does is not recommended for ages 6 months through 4 years.  

CONTACT

NCTracks Contact Center: 800-688-6696

This blog is related to:

https://medicaid.ncdhhs.gov/blog/2022/07/01/special-bulletin-covid-19-256-moderna-pediatric-vaccine