COVID-19 Vaccines

On Jan. 31, 2020, the Secretary of Health and Human Services declared the 2019 novel coronavirus (COVID-19) was a public-health emergency for the United States as of Jan. 27, 2020. In Dec. 2020, the Food and Drug Administration (FDA) began issuing Emergency Use Authorizations for COVID-19 vaccines. A list of COVID-19 products is available through the Formulary search ( Users can search by product name, the 11-digit NDC, or click the "COVID-19 vaccine" checkbox to review details about each vaccine.

Immunization Program Portal

The federal government distributes the COVID-19 vaccines. Pharmacies, retail clinics, providers, and other care sites receiving and administering the COVID-19 vaccine must complete the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Program Provider Agreement.

Providers should contact the Texas Department of State Health Services (DSHS) Immunization Program to register through the Texas DSHS Immunization Portal.

Claim Processing

HHSC set the fee-for-service (FFS) reimbursement rate to align with Medicare. For vaccines requiring a single or two doses, the FFS initial dose's administration reimbursement rate is $40.00. HHSC bases reimbursement on the submitted value in the "Incentive Amount Submitted" field (438-E3). The claim will pay $0 if the field is blank.

The Public Readiness and Emergency Preparedness Act allows certain providers to order and administer the COVID-19 vaccine, including pharmacists and pharmacy interns. To process a pharmacy vaccine administration claim, pharmacy staff should submit the following:

Field Name Field Number Values
Prescriber ID 411-DB
  • Submit the 10-digit National Provider Identifier (NPI) of the administering pharmacist (or supervising pharmacist of the pharmacy staff administering the vaccine). Pharmacy staff without an NPI (e.g., intern) should use the supervising pharmacist's NPI instead.
  • Individuals or organizations can apply for an NPI through the National Plan and Provider Enumeration System.
Prescription Origin Code 419-DJ 05 (Pharmacy)
Submission Clarification Code 42O-DK
  • Pharmacies submitting claims for a single dose of a COVID-19 vaccine do not submit a value.
  • For initial and second doses:
    • 02 (Other Override)
      • Used for the initial dose of a multi-dose COVID-19 vaccine
    • 06 (Starter Dose)
      • Used for the second dose of a multi-dose COVID-19 vaccine
  • For additional or booster doses:
    • 07 (Medically Necessary)
      • Used for an additional or sequential dose of a multi-dose COVID-19 vaccine
    • 10 (Meets Plan Limitations)
      • Used for a booster dose of multi-dose COVID-19 vaccine
      • This includes individuals 18 years and older
Reason for Service Code 439-E4
  • PH (Preventive Health Care)
  • PN (Prescriber Consultation)
  • RF (Health Provider Referral)
Professional Service Code 440-E5 MA (Medication Administration)
Result of Service Code 441-E6 3N (Medication Administration)
Ingredient Cost Submitted 409-D9 $0.01 or $0.00
Incentive Amount Submitted 438-E3
  • $40.00
    • All doses

Pharmacies will receive a rejection for FFS claims when submitting a second dose claim if a client received their first dose from a non-Medicaid pharmacy. If your second dose claim is correct, the pharmacy can submit the following information to bypass the rejection:

Field Name Field Number Values
Reason for Service Code 439-E4 PP (Plan Protocol)
Professional Service Code 440-E5 MA (Medication Administration)
Result of Service Code 441-E6 3N (Medication Administration)