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  • The Centers for Medicare & Medicaid Services (CMS) has indicated no preference for billing COVID-19 vaccines as a medical or pharmacy benefit, but posted a preview cross-walk of CPT, CVX, and NDC-10 codes on November 11, 2020 to aid pharmacies and other providers in their preparations.

    • Medical Benefit: American Medical Association (AMA) Current Procedural Terminology (CPT) Committee released coding conventions for COVID-19 vaccines in November 2020 and updates in January 2021 (see Appendix Q). These include specific vaccine and dose information and will continue to be updated as additional vaccines are authorized. When COVID-19 vaccine administration is covered under the medical benefit, the claim will be transmitted to the pharmacy’s medical intermediary for processing.

    • Pharmacy Benefit: Pharmacy systems are built on National Council for Prescription Drug Programs (NCPDP) standards. NCPDP created a coding convention in December 2020 (updated in January 2021); Table 2 lists required data elements for claim submission. The NCPDP claim format can be used to submit reimbursement to a pharmacy benefit manager (PBM) as a pharmacy benefit claim or to a medical intermediary organization, where it will be converted from a pharmacy to a medical benefit claim.

    • Pharmacies already have the ability to bill either the medical or pharmacy benefit for a given patient. Prior to COVID-19, pharmacies billed for commonly administered vaccines under both the medical and pharmacy benefits. Medicare covers annual influenza vaccinations under Part B, but shingles vaccines under Part D (as but one example).

  • Reimbursement rates and billing processes for COVID-19 vaccine administration are dependent on (1) the patient’s insurance coverage and (2) how the employer, other health plan sponsor, or state healthcare program has decided to cover the vaccine, whether through the medical benefit or pharmacy benefit.

    • Medicare: For COVID-19 vaccine administration services furnished after March 15, 2021, Medicare will pay approximately $40 for each dose in the series; this rate will be geographically adjusted based on where the service is furnished. For COVID-19 vaccine administration services furnished before March 15, 2021, Medicare will pay $28.39 for administration of a single-dose COVID-19 vaccine, or $16.94 for the first dose and $28.39 for a final dose of a multidose vaccine (payments may be geographically adjusted)

    • Commercial and State (i.e., Medicaid, Children’s Health Insurance Program, Basic Health Program): State healthcare programs, like Medicaid, and private sector plans vary in whether COVID-19 vaccines are paid through the medical benefit or the pharmacy benefit, but all are required under the Coronavirus Aid, Relief, and Economic Security (CARES) Act to reimburse in-network and out-of-network vaccine providers for COVID-19 vaccine administration. This is a unique requirement specific to COVID-19 vaccines and preventive services.

  • Uninsured: Providers administering the vaccine to people without health insurance or those whose insurance does not cover COVID-19 vaccine can request reimbursement for the administration of the COVID-19 vaccine through the Provider Relief Fund. To request reimbursement from the fund, pharmacies will need to have a One Healthcare ID, validate their TIN, and set up their direct deposit via Optum Pay. The Relief Fund states that reimbursement requests, including for vaccine administration, are being paid within 30 days.

  • PCMA is collaborating with national pharmacy trade associations and other industries spanning the pharmaceutical supply and payment chain to identify challenges and create solutions in real time, for example:

    • Pharmacies may be collecting patients’ medical cards, pharmacy benefit card, and social security number to enable claims billing for medical or pharmacy claims or seek reimbursement from the Provider Relief Fund.

    • For Medicare, CMS has advised that vaccine administrators need the Medicare Beneficiary Identifier (MBI) for billing, as COVID-19 vaccine administration is being covered under the Medicare Part B benefit—even if a beneficiary is enrolled in a Medicare Advantage plan.

    • PBMs are collaborating across supply chain on recommendations to CMS to ensure beneficiaries are not turned away for bringing the “wrong card” and pharmacists and other providers also are supported in accessing the information they need to file for reimbursement timely.

  • During this time of public health emergency, PBMs know the importance of pharmacies remaining focused on providing patient care. Consistent with state and federal government agencies, pharmacies, and clients, many PBMs are limiting routine pharmacy audits, unless required by law or because of certain fraud, waste, and abuse investigations.

  • PBMs are collaborating with others across the pharmaceutical supply and payment chain to bring together resources relating to COVID-19 vaccine access and to help address concerns quickly.

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