CurrentFidelis CarePolicy N/A

Pharmacy Vaccine Coverage — Covered vaccine products and administration billing guidance

Lists vaccines and NDCs covered for Fidelis Care members enrolled in Child Health Plus, Qualified Health Plans, and the Essential Plan; describes billing rules for administration fees when vaccine obtained through state or federal programs. Affects pharmacies billing for vaccine products and administration for these lines of business.

Policy Summary

PayerFidelis Care

PolicyPharmacy Vaccine Coverage — Covered vaccine products and administration billing guidance

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPharmacies may bill for vaccine administration fees only when the product is obtained under State or Federal programs; refer to vaccine billing guides for documentation and billing procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~40+vaccine products listed

NDCs includedNDCs provided

Child Health Plus / QHP / EPLines of business

State/Federal onlyAdministration billing rule

Vaccine Coverage and Administration Rules

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Covered vaccines (by product/NDC)

Covered vaccine products and NDCs

Vaccine listing: The document lists vaccine products and corresponding NDCs that are covered for specified lines of business; coverage is presented by vaccine category and trade name with NDCs.

Coverage is per the formulary/listing; refer to plan formulary for any additional products or restrictions.

Administration fee billing criteria

Administration billing rule

Administration billing requirement: Pharmacies may bill for vaccine administration fees only when the product is obtained under State or Federal programs (e.g., Vaccines for Children, COVID-19 programs).

Qualified Health Plans and Essential Plan may include product coverage without administration coverage; refer to the formulary and appropriate vaccine billing guides for details.

Pharmacies may bill for vaccine administration fees only when the vaccine product was obtained through State or Federal programs (for example, Vaccines for Children (VFC) or COVID‑19 programs). If the vaccine product was not obtained under these programs, the pharmacy should not submit a separate administration charge. Refer to the applicable vaccine billing guide(s) for details on documentation and billing procedures.

For members enrolled in Qualified Health Plans (Metal Level Products) and the Essential Plan (EP), the plan formulary may list additional vaccines as covered products but will not necessarily cover the administration fee. Always check the formulary and the vaccine billing guidance to confirm whether administration is billable for a given product and line of business.

Vaccine NDCs and Coding Tables

COVID-19 - Pfizer NDCsNDCCovered

00069-2528-01	COMIRNATY 30MCG/0.3ML (>12 y/o)
00069-2528-10	COMIRNATY 30MCG/0.3ML (>12 y/o)
00069-2501-01	COMIRNATY 10MCG/0.3ML (5-11 y/o)
00069-2501-10	COMIRNATY 10MCG/0.3ML (5-11 y/o)

Influenza NDCs (examples)NDCCovered

33332-0125-10	AFLURIA
33332-0125-11	AFLURIA
33332-0025-03	AFLURIA
70461-0025-03	FLUAD
70461-0025-04	FLUAD

Moderna and Hepatitis B NDCs (examples)NDCCovered

80777-0112-01	SPIKEVAX 50MCG/0.5ML (>12 y/o)
80777-0112-88	SPIKEVAX 50MCG/0.5ML (>12 y/o)
80777-0112-96	SPIKEVAX 50MCG/0.5ML (>12 y/o)
43528-0003-01	HEPLISAV-B 20/0.5ML

Shingles and HPV NDCs (examples)NDCCovered

58160-0819-12	SHINGRIX
00006-4119-03	GARDASIL 9
00006-4121-01	GARDASIL 9

Pneumococcal vaccines NDCs (examples)NDCCovered

00005-1971-01	PREVNAR 13
00006-4329-02	VAXNEUVANCE
00005-2000-02	PREVNAR 20
00006-4837-03	PNEUMOVAX 23

Provider Billing and Authorization Actions

Note

Prior Authorization

No prior authorization requirements are specified in this document for pharmacy vaccine coverage.

Step Therapy

No step therapy requirements are stated. Vaccines listed are covered per formulary and program rules; there is no mandated sequence of vaccines or step edits documented here.

Documentation Required

Billing Guide Reference

Refer to the appropriate vaccine billing guide(s) for full documentation, coding, and billing procedures for vaccines and administration fees.

Check payer-specific vaccine billing guides for required documentation and claim submission instructions
Confirm coverage details against the Qualified Health Plans (Metal Level Products) and Essential Plan (EP) formulary

Billing Rule

Administration Billing Restriction

Pharmacies may only bill for the administration fee when the vaccine product was obtained under State or Federal programs (for example, Vaccines for Children (VFC), federally supplied COVID-19 programs, etc.). If the vaccine was not procured under such programs, the administration fee is not billable.

Applies to members enrolled under Child Health Plus (CHP), Qualified Health Plans (Metal Level Products), and Essential Plan (EP)
Confirm program eligibility and vaccine procurement source before billing administration

Policy Background

This document lists vaccine products and corresponding NDCs that are covered for pharmacy dispensing and for administration billing where permitted. It is intended to be used by pharmacies and billing staff to identify covered vaccine trade names and NDC codes for members enrolled in Child Health Plus, Qualified Health Plans, and the Essential Plan.

The listing does not provide clinical indications, dosing schedules, or age‑specific clinical guidance beyond occasional product notes; use clinical references and the vaccine billing guides for administration, age limits, and documentation requirements.

Key Definitions

Administration fee — billing limitation

Who may bill administration feePharmacies may bill the vaccine administration fee only when the vaccine product was obtained under State or Federal programs (e.g., Vaccines for Children, COVID‑19 programs).

When administration fee is not billableIf the vaccine product was not obtained through a State or Federal program, pharmacies should not bill for the administration fee; Qualified Health Plans and the Essential Plan may cover product only, not administration.

Examples of qualifying programsExamples include the Vaccines for Children (VFC) Federal Program and COVID‑19 vaccine programs.

Reference for billing proceduresRefer to the appropriate vaccine billing guide(s) for details on required documentation and billing procedures.

Applicable lines of businessThis administration billing limitation applies to members enrolled in Child Health Plus, Qualified Health Plans (Metal Level), and the Essential Plan.