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TO: All
Pharmacy Providers
RE: Coverage
for Adult Vaccines/COVID Vaccines and Administration (Pharmacy Providers)
Effective September 11, 2023,
Alabama Medicaid will reimburse Medicaid-enrolled pharmacy providers for the
administration and ingredient cost of the commercially distributed COVID
vaccines. Effective October 1, 2023, Alabama Medicaid will reimburse Medicaid-enrolled
pharmacy providers for the administration and ingredient cost of the Advisory Committee
on Immunization Practices (ACIP) recommended vaccines for adults ages 19 and
older. Claims may be retroactively billed to the effective date. Claims for a
vaccine and the administration of the vaccine will be submitted on the same
claim.
Instructions for submitting a
pharmacy claim for a vaccine with the administration fee:
- Pharmacies should submit a claim for
the vaccine (i.e., ingredient) with the appropriate NDC.
- Pharmacies should submit the
administration fee in the Incentive Amount Submitted field
(NCPDP Field 438-E3) on the same claim as
the vaccine (i.e., ingredient).
- A maximum reimbursement of $5 is
allowed for each vaccine administration (current exception of $40
administration for COVID vaccine). Only one dispensing fee (for the ingredient)
and copay (if applicable) will be applied to the claim. Currently, copays
are not applicable to any Medicaid pharmacy claim.
- For a list of ACIP recommended vaccines
please visit the following website:
- A prescription or standing order is
required for each vaccine and administration to be retained on file for
documentation purposes.
- Claims for the administration fee only
with no vaccine/ingredient will be denied.
- To facilitate coordination of care,
Pharmacy providers are required to inform (via phone, fax, email, or mail)
each recipient’s PMP upon administration of any vaccines for which an
administration claim is submitted. Documentation must be kept on file at
the pharmacy of the notification to the PMP. If the PMP is unknown, the
pharmacy may call the Alabama Medicaid Automated Voice Response System
(AVRS) at 1-800- 727-7848 to obtain the PMP information. Pharmacy providers
may also notify the recipient’s local Alabama Coordinated Health Network
(ACHN) region to assist with finding a PMP; ACHN contact information can
be located on the Agency website under Contacts/ACHN Contacts. A suggested
Immunization Provider Notification Letter, which can be used to notify the
PMP, can be found on the Agency website under Pharmacy/Vaccines.
- State and federal laws and regulations
should be followed regarding the dispensing and administration of legend
drugs/vaccines as well as products granted under Emergency Use
Authorization (EUA).
The Current Procedural Terminology (CPT) and Current
Dental Terminology (CDT) codes descriptors, and other data are copyright © 2023 American Medical
Association and © 2023
American Dental Association (or such other date publication
of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.