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.
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.
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:
Pharmacy vs. Medical Benefit Coverage
The member’s health plan will outline whether the claim is considered a medical or pharmacy benefit expense.
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:
Indicates initial dose
Indicates that the previous medication was a starter dose and additional medication is needed to continue treatment
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
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.
Second Dose & Schedule Considerations
Third Dose & Schedule Considerations
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:
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.