fb88Care Updated COVID-19 Vaccine Coverage, CR 109200 
On March 29, 2022, the Office of fb88Care Services (OMS) updated COVID-19 vaccine product and administration coverage by adding codes 91309 and 0094A for Moderna COVID-19 vaccine boosters for ages 18 and up in bold in the following table:   
OMS COVID-19 Vaccine Code Coverage Update Effective March 29, 2022  |
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Pfizer COVID-19 Vaccine Administration for Ages 15 and Up  |
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°ä´Ç»å±ð &²Ô²ú²õ±è; |
¶Ù±ð²õ³¦°ù¾±±è³Ù¾±´Ç²Ô &²Ô²ú²õ±è; |
Code Effective Date  |
Rate Effective 01/01/2022  |
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91300 &²Ô²ú²õ±è; |
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use  |
12/11/2020 &²Ô²ú²õ±è; |
$0** &²Ô²ú²õ±è; |
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0001´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose  |
12/11/2020 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
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0002´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose  |
12/11/2020 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
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0003´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of 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: third dose  |
8/12/2021 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
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0004´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of 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: booster dose  |
9/22/2021 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
Pfizer COVID-19 Vaccine Administration for Ages 5 to 14  |
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91307 &²Ô²ú²õ±è; |
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (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  |
10/29/2021 &²Ô²ú²õ±è; |
$0** &²Ô²ú²õ±è; |
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0071´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of 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: first dose  |
10/29/2021 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
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0072´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of 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: second dose  |
10/29/2021 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
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0073´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of 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; third dose  |
1/3/2022 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
Pfizer Ready-to Use COVID-19 Vaccine Administration for Ages 15 and Up  |
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91305 &²Ô²ú²õ±è; |
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, trissucrose formulation, for intramuscular use  |
1/3/2022 &²Ô²ú²õ±è; |
$0** &²Ô²ú²õ±è; |
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0051´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of 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; first dose  |
1/3/2022 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
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0052´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of 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; second dose  |
1/3/2022 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
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0053´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of 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; third dose  |
1/3/2022 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
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0054´¡â€¯&²Ô²ú²õ±è; |
 Immunization administration by intramuscular injection of 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; booster dose  |
1/3/2022 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
Moderna COVID-19 Vaccine Ages 15 and Up  |
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91301 &²Ô²ú²õ±è; |
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use  |
12/18/2020 &²Ô²ú²õ±è; |
$0** &²Ô²ú²õ±è; |
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0011´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose  |
12/18/2020 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
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0012´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, chimpanzee adenovirus Oxford 1 (ChAdOx1) vector, preservative free, 5x1010 viral particles/0.5mL dosage; second dose  |
12/18/2020 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
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0013´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; third dose  |
8/12/2021 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
Moderna COVID-19 Vaccine Low Dose Booster Ages 15 and Up  |
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91306 &²Ô²ú²õ±è; |
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL dosage, for intramuscular use  |
10/21/2021 &²Ô²ú²õ±è; |
$0** &²Ô²ú²õ±è; |
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0064´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL dosage, booster dose  |
10/20/2021 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
Moderna COVID-19 Vaccine Booster Ages 18 and Up  |
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91309 &²Ô²ú²õ±è; |
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.5 mL dosage, for intramuscular use  |
3/29/2022 &²Ô²ú²õ±è; |
$0** &²Ô²ú²õ±è; |
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0094´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.5 mL dosage, booster dose  |
3/29/2022 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
Johnson & Johnson (Janssen) COVID-19 Vaccine Administration Ages 15 and Up  |
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91303 &²Ô²ú²õ±è; |
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5mL dosage, for intramuscular use  |
2/27/2021-4/12/2021 & 4/23/2021  |
$0** &²Ô²ú²õ±è; |
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0031´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5mL dosage, single dose  |
2/27/2021-4/12/2021 & 4/23/2021  |
$36.98* &²Ô²ú²õ±è; |
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0034´¡â€¯&²Ô²ú²õ±è; |
Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5 mL dosage; booster dose  |
10/20/2021 &²Ô²ú²õ±è; |
$36.98* &²Ô²ú²õ±è; |
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 *fb88Care Usual, Customary, and Reasonable (UCR) Fee Schedule Rate. Section 45: Hospital Services claims shall be Ambulatory Payment Classification (APC) priced in accordance with CMS status.    **Government supplied at no cost and billed with the SL modifier.   |
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 Please contact your Provider Relations Specialist w¾±³Ù³ó q³Ü±ð²õ³Ù¾±´Ç²Ô²õ. â¶Ä¯â¶Ä¯â¶Ä¯&²Ô²ú²õ±è;