On August 12, 2021, the Food and Drug Administration (FDA) amended the emergency use authorizations (EUAs) for the Pfizer-BioNTech COVID-19 Vaccine and the Moderna COVID-19 Vaccine to allow for the use of an additional dose in certain immunocompromised individuals. On September 22, 2021, the FDA amended the EUA to allow a single booster dose. Per the recent National Council for Prescription Drug Programs (NCPDP) guidance, HHSC is revising previous guidance regarding using the Submission Clarification Code (SCC) field (420-DK) . Pharmacy claims for additional and booster doses will require different SCC codes.
The FDA amendment to the EUAs allows for an additional dose of Pfizer-BioNTech or Moderna COVID-19 vaccine in certain immunocompromised individuals. Such individuals include but are not limited to, solid organ transplant recipients, individuals receiving active cancer treatment for tumors or cancers of the blood, and individuals with moderate-to-severe primary immunodeficiency.
As of September 29, pharmacies must submit fee-for-service (FFS) claims for the COVID-19 additional dose for service dates August 12 forward. Pharmacies must submit the additional dose claim with SCC value of “07” (“Medically Necessary”).
MCOs will provide instructions for COVID-19 vaccine additional dose billing through managed care.
On September 24, 2021, the CDC Advisory Committee on Immunization Practices issued guidance regarding the booster dose of Pfizer-BioNTech COVID-19 vaccine. HHSC will allow claims for the Pfizier-BioNTech COVID-19 vaccine booster dose beginning October 27, 2021. Pharmacies must submit SCC value of “10” (“Meets Plan Limitations”) for booster dose claims.
The FDA amendment to the EUAs allows for the use of a single booster dose of Pfizer-BioNTech COVID-19 vaccine, at least six months after completion of the primary series in:
- individuals aged 65 years and older
- long-term care facility residents
- Individuals 18 through 64 years of age with underlying medical conditions
- Individuals 18 through 64 years of age at increased risk for exposure and transmission due to occupational or institutional setting
MCOs will provide instructions for COVID-19 vaccine booster dose billing through managed care.
To assist pharmacies, HHSC updated:
- COVID-19 Vaccine Quick Reference (PDF), to download and make it available to your staff
- Medicaid B1 Payer Sheet (PDF)
Contact the HHSC Pharmacy Benefit Access Help Desk at 1-800-435-4165 with questions about fee-for-service pharmacy claims submission.