Bivalent Pfizer COVID-19 Booster Vaccine Coverage Update

September 15, 2022

Effective August 31, 2022, HHSC will cover the new, bivalent Pfizer-BioNTech COVID-19 booster vaccine as a payable pharmacy benefit.

On August 31, 2022, the U.S. Food and Drug Administration (FDA) amended the Emergency Use Authorizations (EUAs) for the Pfizer-BioNTech COVID-19 vaccine to authorize a new, bivalent formulation designed to stimulate immunity to both the original strain of SARS-CoV-2 virus and the omicron variant. The new, bivalent Pfizer-BioNTech COVID-19 booster vaccine is authorized for individuals 12 years and older. The new vaccine formulation is not intended for use as either of the doses in the primary series. It should be administered as a single booster dose at least two months following completion of either a primary series of COVID-19 vaccines or monovalent booster vaccination.

HHSC allows for pharmacy benefit coverage of the new, bivalent Pfizer-BioNTech COVID-19 booster vaccine in compliance with the EUA issued by the FDA.

HHSC will cover the new, bivalent Pfizer-BioNTech COVID-19 booster vaccine National Drug Codes (NDCs) in the table below for Medicaid and CHIP as a payable pharmacy benefit:

Drug name Dosage NDC
PFIZER COVID BIVAL(12Y UP) MDV-EUA 0.3 mL

59267-0304-02

59267-0304-01

PFIZER COVID BIVAL(12Y UP) SDV-EUA 0.3 mL

59267-1404-02

59267-1404-01

Pharmacies must submit the Submission Clarification Code value of “10” (“Meets Plan Limitations”) for the bivalent Pfizer-BioNTech COVID-19 booster dose claims. MCOs will provide instructions for bivalent Pfizer-BioNTech COVID-19 booster dose billing through managed care.