Pfizer-BioNTech COVID-19 Vaccine

Originally published March 3, 2021
Updated April 15, 2022

This page details the current Medi-Cal billing policy when submitting claims for the administration of the Pfizer-BioNTech COVID-19 vaccine.

Current General Policy

  • Dose administrations may be billed separately, or multiple on the same claim, whichever fits the provider’s billing preferences and practices. Claims submitted should adhere to the timeliness guidelines described in the Part 1 provider manual section, Claim Submission and Timeliness Overview.

  • There is no requirement for the same provider to administer all doses. Each dose is separately reimbursable.

  • Primary vaccination series for individuals 12 years of age and older:

    • The first two doses of the vaccine are effective for dates of service on or after December 11, 2020.

    • The second dose should be administered no earlier than 17 days after the first dose.

    • Effective for dates of service on or after December 11, 2020, the primary vaccination series may be administered to individuals 16 years of age and older.

    • Effective for dates of service on or after May 10, 2021, the primary vaccination series may be administered to individuals 12 years of age and older.

    • The manufacturer of the doses administered to a Medi-Cal beneficiary must remain consistent between the primary vaccination series doses, regardless of the administering provider.
  • Third dose for immunocompromised individuals 12 years of age and older:

    • Effective for dates of service on or after August 12, 2021, a third dose should be administered no earlier than 28 days after the second dose for:

      • Individuals who have undergone solid organ transplantation, or who are diagnosed with conditions that are considered to have an equivalent level of immunocompromise.

  • Booster dose for individuals 12 years of age and older:

    • Effective for dates of service on or after January 3, 2022, all individuals 12 years of age or older are eligible for a single booster dose at least five months after completing the primary vaccination series.

    • Effective for dates of service on or after December 9, 2021, all individuals 16 years of age or older are eligible for a single booster dose at least six months after completing the primary vaccination series.

    • Effective for dates of service on or after November 19, 2021, all individuals 18 years of age or older are eligible for a single booster dose at least six months after completing the primary vaccination series.

    • Effective for dates of service on or after September 22, 2021, the following groups are eligible for a booster shot at six months or more after the primary vaccination series:

      • 65 years and older

      • Age 18+ who live in long-term care settings

      • Age 18+ who have underlying medical conditions

      • Age 18+ who work or live in high-risk settings

    • Moderately and severely immunocompromised individuals aged 18 years of age and older who completed a COVID-19 vaccine primary vaccination series and received a third dose of either the Pfizer-BioNTech or Moderna COVID-19 vaccine may receive a single COVID-19 booster dose (Pfizer-BioNTech, Moderna, or Janssen) at least 6 months after completing their third mRNA vaccine dose. In such situations, individuals who are moderately and severely immunocompromised may receive a total of four COVID-19 vaccine doses.

    • Eligible individuals may choose which vaccine they receive as a booster dose. The eligible population(s) and dosing interval for the heterologous (mix and match) booster dose are the same as those authorized for a booster dose of the vaccine used for primary vaccination.
  • Primary vaccination series for individuals 5 through 11 years of age:

    • Effective for dates of service on or after October 29, 2021, individuals 5 through 11 years of age may receive the primary vaccination series of two doses with the pediatric formulation of the Pfizer-BioNTech COVID-19 vaccine.

    • The second dose should be administered no earlier than 21 days after the first dose.

    • Each dose should be 0.2 mL each, 10 mcg of mRNA, administered intramuscularly.
  • Third dose for immunocompromised individuals 5 years of age and older:

    • Effective for dates of service on or after January 3, 2022, a third dose should be administered no earlier than 28 days after the second dose for:

      • Individuals who have undergone solid organ transplantation, or who are diagnosed with conditions that are considered to have an equivalent level of immunocompromise.

Maximum Allowable Reimbursement

  • Effective for dates of service on or after December 11, 2020 through March 14, 2021:

    • When billed appropriately, providers will be reimbursed up to the maximum allowable amount of $16.94 for a 0.3 mL first dose.

    • When billed appropriately, providers will be reimbursed up to the maximum allowable amount of $28.39 for a 0.3 mL second dose.

  • Effective for dates of service on or after December 11, 2020:

    • Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC) and Tribal FQHC providers, may be reimbursed up to the maximum allowable amount of $67.00 for each dose of the COVID-19 vaccine administered.

  • Effective for dates of service on or after March 15, 2021:

    • When billed appropriately, providers will be reimbursed up to the maximum allowable amount of $40.00 for each 0.3 mL dose (currently for individuals 12 years of age and older).

  • Effective for dates of service on or after June 8, 2021:

    • When billed appropriately, providers will be reimbursed a supplemental amount of $35.00 per dose when administering a COVID-19 vaccine in the home of a Medi-Cal beneficiary who is unable to travel to a vaccination site.

    • Billing instructions on how to claim this additional supplemental amount is available in the Immunizations provider manual section in the appropriate Part 2 manual.

  • Effective for dates of service on or after October 29, 2021:

    • When billed appropriately, providers will be reimbursed up to the maximum allowable amount of $40.00 for each 0.2 mL dose for individuals 5 through 11 years of age.

If claims do not meet the billing instructions listed above or in the following sections, they will be denied or result in an incorrect payment. Additionally, providers should not use the following Current Procedural Terminology (CPT®) codes when billing for these vaccines, as they are not reimbursed by Medi-Cal at this time:

  • 91300 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)] vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted, for intramuscular use)

  • 91305 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)] vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use)

  • 91307 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)] vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use)

If providers bill using this CPT code, they may receive a Remittance Advice Details (RAD) code of 0145: This procedure is not a Medi-Cal benefit on this date of service, and are therefore reminded that the administration of the vaccine is reimbursable at this time, and not the vaccine itself.

Pharmacy Claims

Pharmacy providers seeking to submit hardcopy or electronic claims should refer to the Medi-Cal Rx website for submission and billing instructions.

Medical and Outpatient Claims

  • Individuals equal to or greater than 12 years of age using the originally-authorized formulation (phosphate buffered saline):

    • Administration Code 0001A is for Dose 1

    • Administration Code 0002A is for Dose 2

    • Administration Code 0003A is for Dose 3 (for the immunocompromised)

    • Administration Code 0004A is for the Booster Dose

  • Individuals equal to or greater than 12 years of age using the Tris buffered formulation:

    • Administration Code 0051A is for Dose 1

    • Administration Code 0052A is for Dose 2

    • Administration Code 0053A is for Dose 3 (for the immunocompromised)

    • Administration Code 0054A is for the Booster Dose

  • Individuals 5 through 11 years of age:

    • Administration Code 0071A is for Dose 1

    • Administration Code 0072A is for Dose 2

    • Administration Code 0073A is for Dose 3

    There are no special instructions for hard copy or electronic medical and outpatient submissions

    Examples:

    The examples below are included for reference only. When submitting claims providers are able to bill for administration of each dose separately, or multiple on the same claim form, whichever fits their individual preference or billing practice. The examples below show instances of claims for the administration of the first and second doses separately, but providers should note the images below are merely examples, and that providers should adjust to their billing situation as appropriate. There is no requirement for the same provider to administer all doses. Each dose is separately reimbursable, however the manufacturer of the doses administered to a Medi-Cal beneficiary must remain consistent between the primary vaccination series, regardless of the administering provider. Eligible individuals may choose which vaccine they receive as a booster dose:

    1) Pfizer-BioNTech on a CMS-1500:

    Pfizer BioNTech vaccine CMS-1500

    2) Pfizer-BioNTech on a UB-04:

    Pfizer BioNTech vaccine UB-04

    FDA Approval of Pfizer-BioNTech COVID-19 Vaccine

    On August 23, 2021, the FDA formally approved the biologics license application (BLA) for Pfizer-BioNTech’s COVID-19 vaccine, commercially known as Comirnaty. Currently, the FDA approval applies to the administration of the vaccine in individuals 16 years of age and older.

    The amended Pfizer-BioNTech COVID-19 vaccine EUA still remains in effect however, and allows for:

    • individuals 12 through 15 years of age to receive the Pfizer-BioNTech COVID-19 vaccine,

    • the administration of a third dose to certain immunocompromised individuals,

    • the administration of a booster dose to certain populations,

    • individuals 5 through 11 years of age to receive the pediatric formulation of the Pfizer-BioNTech COVID-19 vaccine,

    • a manufacturing change to include an additional formulation of the Pfizer-BioNTech COVID-19 Vaccine that uses Tris buffer instead of phosphate buffered saline (PBS) used in the originally authorized Pfizer-BioNTech COVID-19 vaccine.

    Medi-Cal’s policy regarding the Pfizer-BioNTech vaccine and the administration of the vaccine, with respect to the formal FDA approval of the Comirnaty product and the existing EUA, remains unchanged. The most current Medi-Cal billing guidelines regarding the Pfizer-BioNTech COVID-19 vaccine is published on this web page.

    Additional References:

    An FAQ regarding the administration of the COVID-19 vaccines is available on the DHCS website. The FAQ is updated as needed.

    For the most current direction regarding whether or not claims should be submitted, and what behavior to expect when submitting, Medi-Cal providers should refer to the “Medical and Outpatient Claim Submissions” tables on the COVID-19 Medi-Cal Response page. Medi-Cal Rx providers should refer to information on the Medi-Cal Rx website.

    This guidance is only effective for COVID-19 vaccines purchased by the federal government. At a future date, DHCS will provide an end date to this temporary policy and instruct providers on how they should bill for the reimbursement of provider purchased COVID-19 vaccines.

    Medi-Cal providers with questions should contact the Telephone Service Center (TSC) Help Desk at 1-800-541-5555, 8 a.m. to 5 p.m., Monday through Friday, except holidays. Border providers and out-of-state billers billing for in-state providers, should call 1-916-636-1200.