Third Dose for Pfizer-BioNTech and Moderna COVID-19 Vaccines Authorized for Certain Populations

Originally published September 3, 2021
Updated September 30, 2021

Effective for dates of service on or after August 12, 2021, the US Food and Drug Administration (FDA) amended the Emergency Use Authorizations (EUA) for the Pfizer-BioNTech and Moderna COVID-19 vaccines to permit the administration of a third dose to certain individuals with compromised immune systems. For the most current direction regarding guidelines for use of these vaccines, including how to bill for the administration of a third dose, refer to the following COVID-19 vaccine web pages:

To assist providers, billing guidelines specific to administration of a third dose are published below.

Providers should note that all billing guidelines included below are only current as of the publication of this article.

General Policy

  • The third dose should be administered no earlier than 28 days following the two-dose regimen of the same vaccine to individuals who have undergone solid organ transplantation, or who are diagnosed with conditions that are considered to have an equivalent level of immunocompromise.

  • Age restrictions for use of the vaccine product are not changed with this update.

  • The policy for maximum allowable reimbursement is not changed with this update.

Pharmacy Claims

  • Use previously published NDCs associated with the Pfizer-BioNTech and Moderna COVID-19 vaccines to indicate the third dose in claims submitted both electronically and on paper. In addition,

    • When submitting electronic claims utilizing NCPDP D.0, NCPDP 1.2, or RTIP transactions, providers should use Submission Clarification Code (SCC) 7 to indicate that a third dose of a COVID-19 vaccine is being administered and billed.

    • When submitting hard copy claims, providers should enter either a 3 or 03 in the Fill Number field (Box 12) to indicate that the third dose is being administered and billed.

  • Batch (NCPDP 1.2) and paper claims (30-1) may be suspended upon submission until further system updates required to properly adjudicate those claims are implemented. Pharmacy providers will be informed when these system updates are implemented.

Medical and Outpatient Claims

  • Pfizer-BioNTech: Administration of a third dose must be indicated by using CPT® code, 0003A.

  • Moderna: Administration of a third dose must be indicated by using CPT code, 0013A.

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. As of the publication of this article, the FDA approval applies to the administration of the vaccine in individuals 16 years of age and older.

The original Pfizer-BioNTech COVID-19 vaccine EUA still remains in effect, however, and allows individuals 12 through 15 years of age to receive the Pfizer-BioNTech COVID-19 vaccine. It also allows for the administration of a third dose to certain immunocompromised individuals.

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 as of the original publication of this article. Providers should refer to the Pfizer-BioNTech COVID-19 Vaccine web page on the Medi-Cal website for the most current billing guidelines that should be followed when submitting a claim to Medi-Cal for the administration of a Pfizer-BioNTech COVID-19 vaccine.

Additional Information

The NCPDP Payer Sheet is updated as of the publication of this article. Provider manual updates reflecting these changes will be released in a future Medi-Cal Update.

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.

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.