CurrentAnthemPolicy N/A

Coverage of additional (third) COVID-19 vaccine dose for certain immunocompromised individuals

Directive from Virginia DMAS that Medicaid (FFS) and MCOs will cover two new vaccine administration codes for a third COVID-19 vaccine dose for certain immunocompromised members; specifies billing/claim processing notes and reimbursement rates for FFS.

Policy Summary

PayerAnthem

PolicyCoverage of additional (third) COVID-19 vaccine dose for certain immunocompromised individuals

Policy CodePolicy N/A

Change TypeInformational / coverage directive

Effective DateAug 12, 2021

Next Review DateN/A

Key ActionPrior authorization is not required; pharmacy claims for a third dose should use Submission Clarification Code = 7, Basis of Cost Determination = 15, and Professional Service Code = MA.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2new vaccine administration codes covered for third dose

$40FFS reimbursement per administration code

91300,91301,91303vaccine product CPTs listed

Not requiredprior auth

Coverage for Additional (Third) COVID-19 Vaccine Dose

Coverage criteria

Coverage for a third COVID-19 vaccine dose is provided for certain immunocompromised individuals in accordance with the FDA's amended EUA and CDC guidance.

Coverage applies to certain immunocompromised individuals as identified by CDC guidance; providers should reference CDC guidance when identifying appropriate patients and timing for a third dose.

ALL of the following

Applies to full benefit Medicaid and FAMIS populations (FFS and MCO members) with dates of service on or after August 12, 2021.
Plan First members: administration codes covered only until the last day of the first calendar quarter that begins one year after the end of the federal public health emergency (per ARPA provisions).

ALL of the following

Policy Summary

PayerAnthem

PolicyCoverage of additional (third) COVID-19 vaccine dose for certain immunocompromised individuals

Policy CodePolicy N/A

Change TypeInformational / coverage directive

Effective DateAug 12, 2021

Next Review DateN/A

Key ActionPrior authorization is not required; pharmacy claims for a third dose should use Submission Clarification Code = 7, Basis of Cost Determination = 15, and Professional Service Code = MA.

SourceLink

On This Page

Covered for third dose administrations of FDA-authorized Pfizer-BioNTech and Moderna COVID-19 vaccines for certain immunocompromised individuals (per amended EUA).

ALL of the following

Two new administration CPT/HCPCS codes for a third dose are covered: 0003A (mRNA 30 mcg/0.3 mL; third dose) and 0013A (mRNA 100 mcg/0.5 mL; third dose).
Vaccine product CPTs listed for reimbursement: 91300, 91301, 91303 (product reimbursement $0.01 as listed).

ALL of the following

Prior authorization is not required for FFS or MCO members for administration of the third dose.
Pharmacy claims for a third dose should use Submission Clarification Code = 7 (medically necessary), Basis of Cost Determination = 15 (free product/no associated cost), and Professional Service Code = MA (Medication Administered).

Vaccine Administration and Product Codes

COVID-19 vaccine administration codes (third dose)CPT | mixedCovered

0003A	Administration, mRNA 30 mcg/0.3 mL; third dose
0013A	Administration, mRNA 100 mcg/0.5 mL; third dose

COVID-19 vaccine product codesCPTCovered

91300	Vaccine product, SARS-CoV-2 mRNA 30 mcg (product CPT) - listed with $0.01 reimbursement
91301	Vaccine product, SARS-CoV-2 mRNA 100 mcg (product CPT) - listed with $0.01 reimbursement
91303	Janssen COVID-19 vaccine product CPT - listed with $0.01 reimbursement

Billing, Authorization, and Pharmacy Claim Instructions

Note

Key Definitions

Certain immunocompromised individuals identified per CDC guidance

DefinitionCertain immunocompromised individuals identified per CDC guidance (see CDC clinical guidance for specific conditions and criteria).

AuthorityCoverage follows FDA EUA amendments authorizing a third dose of Pfizer‑BioNTech and Moderna for these individuals.

ApplicabilityApplies to full‑benefit Medicaid (FFS) and MCO members with dates of service on or after August 12, 2021.

ReferenceProviders should reference CDC guidance: https://www.cdc.gov/coronavirus/2019ncov/vaccines/recommendations/immuno.html for identification and timing.

Plan First NoteCoverage for Plan First members is provided in accordance with ARPA timeframes as noted in the memo.

Additional (third) dose vs booster

DefinitionAn additional (third) dose administered to certain immunocompromised patients to improve primary vaccine series response — not the same as a booster dose for waning immunity.

PurposeGiven to enhance initial immune response in eligible immunocompromised individuals rather than to counteract decreased immunity over time.

Clinical GuidanceTiming and patient selection should follow CDC guidance referenced in the memo.