Pharmacy and Clinical Information

Last update: October 15, 2021, 3:30 p.m. CT

Pharmacies are a critical access point and are heavily involved in vaccine distribution and administration efforts during the national public health emergency. Pharmacies must be enrolled in the Centers for Disease Control and Prevention (CDC)’s Federal Pharmacy Partnership Strategy for COVID-19 Vaccination program. They must also be selected as a participating pharmacy in each jurisdiction in order to be able to receive vaccines from the federal government and administer them to patients.

The information below is specific to pharmacy providers. Visit the COVID-19 Vaccine Guidance page for instructions about submitting medical claims for vaccine administration and information about reimbursement, member cost share and more. 

The cost of Food and Drug Administration (FDA)-authorized COVID-19 vaccine serums will initially be paid for by the U.S. government.

UnitedHealthcare will reimburse for the administration of FDA-authorized COVID-19 vaccines in accordance with applicable state laws and federal provisions, including the CARES Act and FDA Emergency Use Authorization (EUA) guidance. Reimbursement will be for the vaccine administration only. Pharmacies should not charge a separate dispensing fee.

Employer and Individual

Administration fees for in-network providers will be based on contracted rates. Administration fees for out-of-network providers will be based on CMS published rates.

These reimbursement rates apply unless otherwise specified by state regulations. 

UnitedHealthcare and self-funded customers covers the administration of COVID-19 FDA-authorized vaccines with no cost share for in- and out-of-network providers, during the national public health emergency period.

Medicare Advantage

Administration fees for Medicare plans will be covered by Medicare Fee-for-Service (FFS) and be reimbursed according to CMS published rates for both in-network and out-of-network providers.

Medicaid

For members covered under UnitedHealthcare Medicaid (Community Plan) benefit plans, UnitedHealthcare will pay at state-designated rates, unless specified otherwise. State-specific rules and other state regulations may apply. Some state agencies have not yet advised how they will cover this benefit or their reimbursement strategy. Please refer to your state-specific website or your state’s UnitedHealthcare Community Plan website for more details. 

Pharmacies are allowed to bill UnitedHealthcare directly for vaccine administration claims, when applicable. Two initial claim billing processes are available:

  1. Pharmacy platform
    • Pharmacies are allowed to submit vaccine administration claims using the same platform used to submit typical pharmacy claims for a drug
      • Specific guidance on how to submit claims has been provided to pharmacies
    • This will cover both in- and out-of-network pharmacies that have access to the vaccine
  2. UnitedHealth Networks (UHN) vaccine network
    • Vaccination providers may bill the UnitedHealthcare medical benefit through the already established network maintained by UHN
      • This only includes a sub-set of pharmacy providers that currently participate in the established vaccine network. This will not be available to pharmacies that don’t currently participate in the network contracted through UnitedHealthcare

Pharmacy vs. Medical Benefit Coverage

The member’s health plan will outline whether the claim is considered a medical or pharmacy benefit expense.

  • Employer and Individual Fully Insured plans, including Exchanges: For pharmacy benefits that currently provide coverage for vaccines, such as the flu shot, pharmacies were able to submit the claim through the pharmacy benefit as of Dec. 14, 2020. Effective Jan. 13, 2021, coverage for COVID-19 vaccines was added to all Fully Insured plans that do not currently offer vaccine coverage under the pharmacy benefit.
    • Additional information will be provided as it becomes available for USHEALTH Group (USHG).
  • Self-Funded Employer (ASO) plans: Coverage for the COVID-19 vaccine administration has been added.
  • Medicare: Coverage for the COVID-19 vaccine for plans with Part D will be administered under Medicare Part B under the medical benefit through 2021.
    • For 2020 and 2021, charges for the COVID-19 vaccine and vaccine administration should be billed to the CMS Medicare Administrative Contractor (MAC). The MAC will reimburse claims for Medicare members with no cost share for the remainder of 2020 and through 2021. For more information, visit the CMS COVID-19 Insurer’s Toolkit.
    • The patient’s Medicare Beneficiary Identifier (Medicare ID) must be included with claims submitted to the MAC. Many patients do not carry their Medicare ID card with them, and your office may only have the member’s UnitedHealthcare ID number on file, which is different than the Medicare ID. To assist with MAC claim submission, there are three ways to locate that information:
      • Pharmacy claims: If a member is at the pharmacy and doesn’t have their Medicare ID number, the pharmacist may be able to get assistance by calling the OptumRx pharmacy help desk.
      • Medical claims: UnitedHealthcare has added the Medicare ID to the Eligibility & Benefits information available on the UnitedHealthcare Provider Portal. This reference guide has step-by-step instructions on how to find the Medicare ID.
      • Member Medicare ID access: Members can check their Medicare ID number by signing into myMedicare.gov. If a member doesn’t have a myMedicare.gov account yet, they can ‘create an account’ and follow the instructions. For questions, members can call 1-800-MEDICARE (800-633-4227 TTY 877-486-2048).
  • Medicaid: For Medicaid and other state-specific regulations, please refer to your state-specific website or your state’s UnitedHealthcare Community Plan website, if applicable. Some state agencies have not yet advised how they will cover this benefit or their reimbursement strategy. Although these claims may be administered through the pharmacy platform, in some markets, these costs may be treated as a medical benefit expense or billed directly to the state’s Fee-For-Service (FFS) program.

National Council for Prescription Drug Programs (NCPDP) has designated 2 submission clarification codes (SCC) for pharmacy billing as the differentiating value for the dose currently being administered. OptumRx® is updating its claims system to allow different reimbursement rates, based on the submitted SCC and professional service code value from the pharmacy:

SCC/PSC Value

Description

SCC 2

Indicates initial dose

SCC 6

Indicates that the previous medication was a starter dose and additional medication is needed to continue treatment

SCC 7

Indicates an additional dose is medically necessary, based on CDC recommendations*

“MA” (Medication Administered)

Indicates that pharmacies can submit claims with a DUR PPS code = MA to trigger an administration fee


*The CDC recommends that people with moderately to severely compromised immune systems receive an additional dose of mRNA COVID-19 vaccine at least 28 days after a second dose of either the Pfizer-BioNTech COVID-19 vaccine or Moderna COVID-19 vaccine. CDC has not issued a recommendation for additional doses for any other population at this time.

Additional information on billing pharmacy claims can be found in the NCPDP Emergency Preparedness Guidance –COVID-19 Vaccines guide.

Per the CDC, COVID-19 vaccines are highly effective at preventing people from getting COVID-19 and may help keep people from getting seriously ill, even if they do get COVID-19. Vaccines may also protect the general population around you, particularly those at increased risk for severe illness from COVID-19. For the latest COVID-19 vaccine information, visit the CDC’s overview pages for Johnson & Johnson’s Janssen, Pfizer and Moderna

Here’s a summary of Centers for Disease Control and Prevention (CDC) guidance on things to consider or questions members may have as they determine if and when to get a COVID-19 vaccination.

Pre-Vaccination Considerations

  • COVID-19 Vaccines and Flu Vaccines: Per the CDC, it is no longer necessary to wait 14 days between COVID-19 vaccines and other vaccines, including the influenza vaccine. You may even be able to get the COVID-19 vaccine and other vaccines on the same day.
    • The CDC says that routine flu vaccination is an important preventive care service for children, adolescents, and adults (including pregnant people) that should not be delayed because of the COVID-19 pandemic.
    • The possible side effects of vaccines are generally the same when given alone or with other vaccines. Before receiving any vaccines, members should have a discussion with their physician or health care provider regarding recent or planned vaccines and history of allergic reactions.
  • Prior/Current Infection: Testing to assess for acute or prior infection is not required to receive a COVID-19 vaccine. However, members should continue to follow the guidance of their physician or health care provider. If someone has had a recent COVID-19 infection, COVID-19 vaccination should be deferred until they have recovered from the acute illness (if the person had symptoms) and criteria have been met for them to discontinue isolation.
    • This recommendation applies to anyone who develops a COVID-19 infection before receiving any vaccine doses, as well as those who develop a COVID-19 infection after the first dose of the Pfizer-BioNTech or Moderna vaccine, but before the second dose.
    • While there is no minimum interval recommended, anyone with a documented recent COVID-19 infection may delay vaccination for up to 90 days after the acute illness. Reinfection appears to be uncommon during the initial 90 days after symptom onset of the preceding infection. However, members should follow the guidance of their physician or health care provider.
  • Pregnancy Considerations: COVID-19 vaccination is recommended by the CDC for all people age 12 years and older, including people who are pregnant, breastfeeding, trying to get pregnant now, or might become pregnant in the future. Pregnant and recently pregnant people are more likely to get severely ill with COVID-19 compared with non-pregnant people. Getting a COVID-19 vaccine can protect you from severe illness from COVID-19.
  • Monoclonal Antibody Treatment: COVID-19 vaccination should be delayed for at least 90 days after infusion of monoclonal antibodies or convalescent plasma treatment when used to treat COVID-19. It also applies to those who receive monoclonal antibodies or convalescent plasma after the first dose of the Pfizer-BioNTech or Moderna vaccine, but before the second dose. In this case, the second dose of COVID-19 vaccine should be deferred for at least 90 days following receipt of monoclonal antibodies or convalescent plasma. However, COVID-19 vaccination doesn’t need to be delayed for persons receiving antibody therapies not specific to COVID-19 treatment.
    • However, COVID-19 vaccination does not need to be delayed for persons receiving antibody therapies not specific to COVID-19 treatment

Second Dose & Schedule Considerations

  • Both doses of the COVID-19 vaccine series should be completed with the same product. For example, if a member receives the Pfizer-BioNTech product as their first dose of COVID-19 vaccine, the second dose should be the Pfizer-BioNTech product as well. 
    • In the unusual circumstance where the vaccine product administered for the first dose cannot be determined, is no longer available or is temporarily unavailable, the CDC has published guidance regarding the interchangeability of COVID-19 vaccine products.
  • For two-dose vaccines, if a member must receive the second dose of COVID-19 vaccine earlier than recommended, they may receive it within a grace period of 4 days earlier than the recommended interval for the second dose.
  • If a member must receive the second dose of COVID-19 vaccine later than recommended, they may receive it up to 6 weeks (42 days) after the first dose. There is no need to restart the series if second dose of COVID-19 vaccine is administered earlier than the grace period or beyond 6 weeks.

Third Dose & Schedule Considerations

  • On Aug. 12, 2021, the CDC recommended an extra dose of the mRNA COVID-19 vaccines for certain immunocompromised people as defined by the CDC. The FDA updated the emergency use authorization (EUA) for both Pfizer-BioNTech and Moderna COVID-19 vaccines to allow for the additional dose.
    • The CDC has not issued a recommendation for additional doses for any other population at this time.
    • Per the CDC, there is not enough information at this time to recommend an additional dose of the Johnson & Johnson Janssen COVID-19 vaccine for immunocompromised people, nor is there a recommendation to start another vaccine series. The CDC and FDA are actively working to provide guidance on this matter.
  • The CDC recommends that people with moderately to severely compromised immune systems receive an additional dose of mRNA COVID-19 vaccine at least 28 days after a second dose of Pfizer-BioNTech COVID-19 vaccine or Moderna COVID-19 vaccine.
    • The third dose should ideally be the same manufacturer as the first 2 doses. There is not a recommendation to start another vaccine series for the third dose. If the same vaccine product given for the first two doses is not available or is unknown, either the Pfizer-BioNTech or Moderna COVID-19 vaccine product may be administered.
  • Patients are being encouraged to talk with their physician or health care provider about their medical condition and whether getting an additional dose is appropriate for them.
    • People who are immunocompromised, and those who live with them, should continue to wear face masks, physically distance and wash hands regularly when outside of their household.

Post-Vaccination Considerations

  • COVID-19 antibody testing is not currently recommended to confirm an immune response after vaccination.
  • Members who receive the COVID-19 vaccine should continue to follow all current guidance, including wearing face masks, to protect themselves and others.
  • Fully vaccinated persons with an exposure to someone with suspected or confirmed COVID-19 are not required to quarantine as their risk of infection is low.
    • However, fully vaccinated people should still monitor themselves for symptoms of COVID-19 for 14 days after an exposure. Fully vaccinated people who experience symptoms of COVID-19 should isolate themselves from others, be evaluated by their physician or health care provider, and get tested, if recommended.
    • People are considered fully vaccinated for COVID-19 two weeks after they receive the second dose in a 2-dose series (Pfizer-BioNTech or Moderna vaccines) or two weeks after they receive a single-dose vaccine (Janssen vaccine). However, people with immunocompromising conditions or other concerns should discuss this with their physician or health care provider, if they have any questions about their individual situation.

COVID-19 Vaccines and Vaccine Administration

The cost of FDA-authorized COVID-19 vaccine serums will initially be paid for by the U.S. government. Coverage of vaccine administration is as follows:

  • Employer and Individual: For Employer and Individual health plans, including Individual Exchange plans, UnitedHealthcare and self-funded customers cover the administration of COVID-19 FDA-authorized vaccines with no cost share for in- and out-of-network providers during the national public health emergency period, currently scheduled to end Jan. 15, 2022.  This includes administration of a third dose to those who are moderately to severely immunocompromised as defined by the CDC. Implementation for self-funded customers may vary.
  • Medicare Advantage: The CMS Medicare Administrative Contractor (MAC) will reimburse claims for Medicare members with no cost share through 2021. This includes administration of a third dose to those who are moderately to severely immunocompromised as defined by the CDC. More information is in the CMS Toolkit on COVID-19 Vaccines.
  • Medicaid: CMS has mandated that states must cover COVID-19 vaccine administration fees with a $0 cost share. Some state agencies have not yet advised how they will cover this benefit or their reimbursement strategy. Although these claims may be administered through the pharmacy platform, in some markets, these costs may be treated as a medical benefit expense or billed directly to the state’s Fee-for-Service (FFS) program.

Reminder: You should not bill UnitedHealthcare members at the time of service for any costs associated with the COVID-19 vaccine. Claims for vaccine administration should be submitted as outlined, based on the member’s benefit plan. There is no cost to the member for the COVID-19 vaccine, and most plans are covering the administration of the COVID-19 vaccine at no cost share for the member.

COVID-19 Vaccination Side Effects

Although mild to moderate adverse effects are relatively common following vaccine administration, side effects requiring medical treatment are rare. In the event a vaccine side effect does require a patient to seek medical care, those services will be covered according to their benefit plan. Standard member cost sharing will apply.

Claims for treatment of COVID-19 side effects should be billed according to the service(s) provided. There are not specific codes to use with these claims to indicate treatment of COVID-19 side effects.

Pharmacies must enroll in the CDC’s Federal Pharmacy Partnership Strategy for COVID-19 Vaccination program to administer the vaccine. Pharmacies will make their own determination on whether they will enroll in the program. Retail pharmacies participating in the federal COVID-19 vaccine distribution program vary by state. You may view the full list on the CDC website.

COVID-19 Vaccine Resource Locator

UnitedHealthcare has developed a ZIP-code-based Vaccine Resource Locator to help members and health care professionals find FDA-authorized vaccine resources near them. The resources include information on who can get a vaccine, where vaccines are being given, how to schedule an appointment to get a vaccine and how to sign up for alerts. Please share this locator with your patients or use it yourself to help answer patient questions.

The U.S. Department of Health and Human Services (HHS) has provided authority for pharmacists to order and administer COVID-19 vaccines during the national public health emergency period. It allows interns and technicians with acceptable credentialing to administer vaccines under the authority of a pharmacist. Each state jurisdiction will provide credentialing requirements for vaccination providers.