Coverage of Commercialized COVID-19 Vaccines through Pharmacy Benefit

HHSC now covers the following commercial COVID-19 vaccines as a pharmacy benefit in Medicaid and the Children’s Health Insurance Program (CHIP) that were recently approved by the Food and Drug Administration (FDA) for Emergency Use Authorization (EUA):

• FDA approval Sept. 11, 2023:
  • 2023-2024 Pfizer-BioNTech COVID-19 Vaccine
  • 2023-2024 Moderna COVID-19 Vaccine
• FDA approval Oct. 3, 2023:
  • 2023-2024 Novavax COVID-19 Vaccine

The new commercialized vaccines include a monovalent (single) component corresponding with the Omicron variant XBB.1.5. Unlike previous doses provided at no cost, commercialized COVID-19 vaccines are for purchase.
HHSC began covering the vaccines listed below for traditional fee-for-service Medicaid starting Nov. 20. Managed care organizations (MCOs) will begin coverage no later than Dec. 5.

HHSC backdated the effective date of formulary coverage to match the FDA approval dates below:

• Sept. 11 for the Pfizer and Moderna vaccines
• Oct. 3 for the Novavax vaccine.

The Submission Clarification Code field (420-DK) is no longer required when submitting COVID-19 vaccine claims.