COVID-19 Vaccines and Coverage

Dec. 18, 2020
Updated Dec. 21, 2020
Updated March 11, 2021

In the face of the COVID-19 pandemic, pharmaceutical companies have moved to produce vaccines. The Food and Drug Administration (FDA) has awarded an Emergency Use Authorization (EUA) to three companies for their vaccines: Pfizer on Dec. 11, 2020, Moderna on Dec. 18, 2020, and Janssen Pharmaceutical Companies of Johnson & Johnson on Feb. 27, 2021

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

Initially, the federal government will pay for the vaccine. Blue Cross and Blue Shield of Montana (BCBSMT), 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.

Medicaid

  • Most Medicaid members will have no cost-sharing on vaccines from in- and out-of-network providers. See the CMS Medicaid toolkit for more details.

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 .

When billing a vaccine administration code with an office visit, if the vaccine is not the primary purpose of the office visit, bill the vaccine on a separate claim.

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

91303

Vaccine

Janssen/Johnson & Johnson - Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x10 viral particles/0.5mL dosage, for intramuscular use

0031A

Admin

Janssen/Johnson & Johnson - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5mL dosage, single dose


Dosage: Candidate vaccines may require one or two doses. The Pfizer and Moderna vaccines require two doses. The Janssen/Johnson & Johnson vaccine is one dose.

More information:

  • CDC COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations
  • Provider Relief Fund – for reimbursement for administering the COVID-19 vaccine to the uninsured
  • CMS Medicaid Toolkit - Coverage and Reimbursement of COVID-19 Vaccines, Vaccine Administration, and Cost Sharing under Medicaid, the Children’s Health Insurance Program, and Basic Health Program
  • CMS guidance 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 .

By clicking this link, you will go to a new website/app (“site”). This new site may be offered by a vendor or an independent third party. The site may also contain non-Medicare related information. In addition, some sites may require you to agree to their terms of use and privacy policy.