On Dec. 8, 2022, HHSC began coverage of the bivalent Pfizer-BioNTech and Moderna COVID-19 booster vaccines for younger age groups as a pharmacy benefit in compliance with the EUA issued by the FDA.
Pharmacies must submit the Submission Clarification Code value of “10” (“Meets Plan Limitations”) for bivalent Pfizer-BioNTech and Moderna COVID-19 booster dose claims. MCOs will provide instructions for third and booster dose billing through managed care. Refer to the COVID-19 Vaccine section of the Pharmacy Provider Procedure Manual for more information.
HHSC will cover the administration of the new, bivalent Pfizer-BioNTech and Moderna COVID-19 booster vaccine as non-risk and continue to follow the COVID-19 non-risk payment (NRP) process.
Pfizer-BioNTech
Children down to 6 months are authorized for the bivalent Pfizer-BioNTech COVID-19 vaccine who have not yet begun their three-dose primary series of the Pfizer-BioNTech COVID-19 vaccine or have not yet received the third dose of their primary series will now receive the updated bivalent Pfizer-BioNTech COVID-19 vaccine as the third dose in their primary series following two doses of the original monovalent Pfizer-BioNTech COVID-19 vaccine.
Children 6 months through 4 years who have already completed their three-dose primary series with the original monovalent Pfizer-BioNTech COVID-19 Vaccine will not be eligible for a booster dose of an updated bivalent vaccine at this time.
Pfizer-BioNTech developed a new formulation for the bivalent COVID-19 vaccine specific to the younger age group.
HHSC added the following national drug codes (NDCs) to the Medicaid and CHIP formulary as a payable pharmacy benefit for children 6 months through 4 years, effective Dec. 8:
| NDC | Drug Name | Dose |
|---|---|---|
| 59267-0609-01 | PFIZER COVID BIVAL (6MO-4Y) EUA | 0.2 mL |
| 59267-0609-02 | PFIZER COVID BIVAL (6MO-4Y) EUA | 0.2 mL |
Moderna
Children down to 6 months are authorized for the updated bivalent Moderna COVID-19 booster vaccine after at least two months following completion of the primary monovalent vaccination series.
Moderna developed a new formulation for the bivalent COVID-19 vaccine specific to the younger age group.
HHSC added the following national drug codes (NDCs) to the Medicaid and CHIP formulary as a payable pharmacy benefit for children 6 months through 5 years of age, effective Dec. 8:
| NDC | Drug Name | Dose |
|---|---|---|
| 80777-0283-02 | MODERNA COVID BIVAL (6MO-5Y) EUA | 0.2 mL |
| 80777-0283-99 | MODERNA COVID BIVAL (6MO-5Y) EUA | 0.2 mL |
Resources
- Coronavirus (COVID-19) Update: FDA Authorizes Updated (Bivalent) COVID-19 Vaccines for Children Down to 6 Months of Age
- FDA fact sheet for health care providers administering Pfizer-BioNTech bivalent boosters (PDF)
- FDA fact sheet for health care providers administering Moderna bivalent boosters (PDF)
- Moderna COVID-19 Vaccine: Vaccine Appearance, Preparation, and Administration Summary (PDF)
- Pfizer-BioNTech COVID-19 Vaccine: Appearance, Preparation, and Administration Summary (PDF)