Medicare Part B Payment for COVID-19 Vaccines and Certain Monoclonal Antibodies during the Public Health Emergency
CMS has released a set of toolkits for providers, states and insurers to help the health care system prepare and assist in swiftly administering these products once they become available. These resources are designed to increase the number of providers that can administer the products and ensure adequate reimbursement for administration in Medicare, while making it clear to private insurers and Medicaid programs their responsibility to cover these products at no charge to beneficiaries. This webpage provides the payment allowances and other related information for these products. For more information, review the COVID-19 provider toolkit.
Payment Allowances and Effective Dates for COVID-19 Vaccines and their Administration During the Public Health Emergency: (DOS = Date of Service, TBD = To Be Determined)
CPT Code or HCPCS Code |
CPT or HCPCS Short Descriptor |
Labeler Name |
Vaccine/Procedure Name |
National Payment Allowance Effective for Claims with DOS on or after 03/15/2021 |
National Payment Allowance Effective for Claims with DOS through 03/14/2021 |
Effective Dates |
---|---|---|---|---|---|---|
91300 |
SARSCOV2 VAC 30MCG/0.3ML IM |
Pfizer |
Pfizer-BioNTech Covid-19 Vaccine (Aged 12 years and older) (Purple Cap) |
$0.010[1] |
$0.010[1] |
12/11/2020 – TBD |
0001A |
ADM SARSCOV2 30MCG/0.3ML 1ST |
Pfizer |
Pfizer-BioNTech Covid-19 Vaccine (Purple Cap) Administration – First Dose |
$40.000[2] |
$16.940[2] |
12/11/2020 – TBD |
0002A |
ADM SARSCOV2 30MCG/0.3ML 2ND |
Pfizer |
Pfizer-BioNTech Covid-19 Vaccine (Purple Cap) Administration – Second Dose |
$40.000[2] |
$28.390[2] |
12/11/2020 – TBD |
0003A |
ADM SARSCOV2 30MCG/0.3ML 3RD |
Pfizer |
Pfizer-BioNTech Covid-19 Vaccine (Purple Cap) Administration – Third Dose |
$40.000[2] |
Code not active during this time |
08/12/2021 – TBD |
0004A[4] |
ADM SARSCOV2 30MCG/0.3ML BST |
Pfizer |
Pfizer-BioNTech Covid-19 Vaccine (Purple Cap) Administration – Booster |
$40.000[2] |
Code not active during this time |
09/22/2021 – TBD |
91301 |
SARSCOV2 VAC 100MCG/0.5ML IM |
Moderna |
Moderna Covid-19 Vaccine (Aged 12 years and older) (Red Cap) |
$0.010[1] |
$0.010[1] |
12/18/2020 – TBD |
0011A |
ADM SARSCOV2 100MCG/0.5ML1ST |
Moderna |
Moderna Covid-19 Vaccine (Red Cap) Administration – First Dose |
$40.000[2] |
$16.940[2] |
12/18/2020 – TBD |
0012A |
ADM SARSCOV2 100MCG/0.5ML2ND |
Moderna |
Moderna Covid-19 Vaccine (Red Cap) Administration – Second Dose |
$40.000[2] |
$28.390[2] |
12/18/2020 – TBD |
0013A |
ADM SARSCOV2 100MCG/0.5ML3RD |
Moderna |
Moderna Covid-19 Vaccine (Red Cap) Administration – Third Dose |
$40.000[2] |
Code not active during this time |
08/12/2021 – TBD |
91302 |
SARSCOV2 VAC 5X10^10VP/.5MLIM |
AstraZeneca |
AstraZeneca Covid-19 Vaccine |
$0.010[1] |
Code not active during this time |
xx/xx/xxxx – TBD |
0021A |
ADM SARSCOV2 5X10^10VP/.5ML 1 |
AstraZeneca |
AstraZeneca Covid-19 Vaccine Administration – First Dose |
$40.000[2] |
Code not active during this time |
xx/xx/xxxx – TBD |
0022A |
ADM SARSCOV2 5X10^10VP/.5ML 2 |
AstraZeneca |
AstraZeneca Covid-19 Vaccine Administration – Second Dose |
$40.000[2] |
Code not active during this time |
xx/xx/xxxx – TBD |
91303 |
SARSCOV2 VAC AD26 .5ML IM |
Janssen |
Janssen Covid-19 Vaccine (Aged 18 years and older)[3] |
$0.010[1] |
$0.010[1] |
02/27/2021 – TBD |
0031A |
ADM SARSCOV2 VAC AD26 .5ML |
Janssen |
Janssen Covid-19 Vaccine Administration - First Dose[3] |
$40.000[2] |
$28.390[2] |
02/27/2021 – TBD |
0034A |
ADM SARSCOV2 VAC AD26 .5ML B |
Janssen |
Janssen Covid-19 Vaccine Administration - Booster[3] |
$40.000[2] |
Code not active during this time |
10/20/2021 – TBD |
91304 |
SARSCOV2 VAC 5MCG/0.5ML IM |
Novavax |
Novavax Covid-19 Vaccine, Adjuvanted (Aged 12 years and older) |
$0.010[1] |
Code not active during this time |
07/13/2022 – TBD |
0041A |
ADM SARSCOV2 5MCG/0.5ML 1ST |
Novavax |
Novavax Covid-19 Vaccine, Adjuvanted Administration – First Dose |
$40.000[2] |
Code not active during this time |
07/13/2022 – TBD |
0042A |
ADM SARSCOV2 5MCG/0.5ML 2ND |
Novavax |
Novavax Covid-19 Vaccine, Adjuvanted Administration – Second Dose |
$40.000[2] |
Code not active during this time |
07/13/2022 – TBD |
0044A |
ADM SARSCOV2 5MCG/0.5ML BST |
Novavax |
Novavax Covid-19 Vaccine, Adjuvanted Administration - Booster |
$40.000[2] |
Code not active during this time |
10/19/2022 – TBD |
91305 |
SARSCOV2 VAC 30 MCG TRS-SUCR |
Pfizer |
Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Aged 12 years and older) (Gray Cap) |
$0.010[1] |
Code not active during this time |
01/03/2022 – TBD |
0051A |
ADM SARSCV2 30MCG TRS-SUCR 1 |
Pfizer |
Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Gray Cap) Administration - First dose |
$40.000[2] |
Code not active during this time |
01/03/2022 – TBD |
0052A |
ADM SARSCV2 30MCG TRS-SUCR 2 |
Pfizer |
Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Gray Cap) Administration - Second dose |
$40.000[2] |
Code not active during this time |
01/03/2022 – TBD |
0053A |
ADM SARSCV2 30MCG TRS-SUCR 3 |
Pfizer |
Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Gray Cap) Administration - Third dose |
$40.000[2] |
Code not active during this time |
01/03/2022 – TBD |
0054A[4] |
ADM SARSCV2 30MCG TRS-SUCR B |
Pfizer |
Pfizer-BioNTech Covid-19 Vaccine Pre-Diluted (Gray Cap) Administration - Booster |
$40.000[2] |
Code not active during this time |
01/03/2022 – TBD |
91306 |
SARSCOV2 VAC 50MCG/0.25ML IM |
Moderna |
Moderna Covid-19 Vaccine (Aged 18 years and older) (Red Cap) (Low Dose) |
$0.010[1] |
Code not active during this time |
10/20/2021 – TBD |
0064A[4] |
ADM SARSCOV2 50MCG/0.25MLBST |
Moderna |
Moderna Covid-19 Vaccine (Red Cap) (Low Dose) Administration - Booster |
$40.000[2] |
Code not active during this time |
10/20/2021 – TBD |
91307 |
SARSCOV2 VAC 10 MCG TRS-SUCR |
Pfizer |
Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 5 years through 11 years) (Orange Cap) |
$0.010[1] |
Code not active during this time |
10/29/2021 - TBD |
0071A |
ADM SARSCV2 10MCG TRS-SUCR 1 |
Pfizer |
Pfizer-BioNTech Covid-19 Pediatric Vaccine (Orange Cap) Administration - First dose |
$40.000[2] |
Code not active during this time |
10/29/2021 - TBD |
0072A |
ADM SARSCV2 10MCG TRS-SUCR 2 |
Pfizer |
Pfizer-BioNTech Covid-19 Pediatric Vaccine (Orange Cap) Administration - Second dose |
$40.000[2] |
Code not active during this time |
10/29/2021 - TBD |
0073A |
ADM SARSCV2 10MCG TRS-SUCR 3 |
Pfizer |
Pfizer-BioNTech Covid-19 Pediatric Vaccine (Orange Cap) Administration - Third dose |
$40.000[2] |
Code not active during this time |
01/03/2022 - TBD |
0074A[4] |
ADM SARSCV2 10MCG TRS-SUCR B |
Pfizer |
Pfizer-BioNTech Covid-19 Pediatric Vaccine (Orange Cap) Administration - Booster |
$40.000[2] |
Code not active during this time |
05/17/2022 - TBD |
91308 |
SARSCOV2 VAC 3MCG TRS-SUCR |
Pfizer |
Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) |
$0.010[1] |
Code not active during this time |
06/17/2022 - TBD |
0081A |
ADM SARSCOV2 3MCG TRS-SUCR 1 |
Pfizer |
Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration - First dose |
$40.000[2] |
Code not active during this time |
06/17/2022 - TBD |
0082A |
ADM SARSCOV2 3MCG TRS-SUCR 2 |
Pfizer |
Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration - Second dose |
$40.000[2] |
Code not active during this time |
06/17/2022 - TBD |
0083A |
ADM SARSCOV2 3MCG TRS-SUCR 3 |
Pfizer |
Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration - Third dose |
$40.000[2] |
Code not active during this time |
06/17/2022 - TBD |
91309 |
SARSCOV2 VAC 50MCG/0.5ML IM |
Moderna |
Moderna Covid-19 Vaccine (Aged 6 years through 11 years or aged 18 years and older) (Blue Cap with purple border) 50MCG/0.5ML[5] |
$0.010[1] |
Code not active during this time |
03/29/2022 - TBD |
0091A |
ADM SARSCOV2 50 MCG/.5 ML1ST |
Moderna |
Moderna Covid-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) Administration - First dose |
$40.000[2] |
Code not active during this time |
06/17/2022 - TBD |
0092A |
ADM SARSCOV2 50 MCG/.5 ML2ND |
Moderna |
Moderna Covid-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) Administration - Second dose |
$40.000[2] |
Code not active during this time |
06/17/2022 - TBD |
0093A |
ADM SARSCOV2 50 MCG/.5 ML3RD |
Moderna |
Moderna Covid-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) Administration - Third dose |
$40.000[2] |
Code not active during this time |
06/17/2022 - TBD |
0094A[4] |
ADM SARSCOV2 50MCG/0.5 MLBST |
Moderna |
Moderna Covid-19 Vaccine (Aged 18 years and older) (Blue Cap with purple border) 50MCG/0.5ML Administration - Booster |
$40.000[2] |
Code not active during this time |
03/29/2022 - TBD |
91311 |
SARSCOV2 VAC 25MCG/0.25ML IM |
Moderna |
Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) 250MCG/0.25ML |
$0.010[1] |
Code not active during this time |
06/17/2022 - TBD |
0111A |
ADM SARSCOV2 25MCG/0.25ML1ST |
Moderna |
Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) Administration - First dose |
$40.000[2] |
Code not active during this time |
06/17/2022 - TBD |
0112A |
ADM SARSCOV2 25MCG/0.25ML2ND |
Moderna |
Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) Administration - Second dose |
$40.000[2] |
Code not active during this time |
06/17/2022 - TBD |
0113A |
ADM SARSCOV2 25MCG/0.25ML3RD |
Moderna |
Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) Administration - Third dose |
$40.000[2] |
Code not active during this time |
06/17/2022 - TBD |
91312 | SARSCOV2 VAC BVL 30MCG/0.3M | Pfizer | Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product (Aged 12 years and older) (Gray Cap) | $0.010[1] | Code not active during this time | 08/31/2022 – TBD |
0124A | ADM SARSCV2 BVL 30MCG/.3ML B | Pfizer | Pfizer-BioNTech COVID-19 Vaccine, Bivalent (Gray Cap) Administration – Booster Dose | $40.000[2] | Code not active during this time | 08/31/2022 – TBD |
91313 | SARSCOV2 VAC BVL 50MCG/0.5ML | Moderna | Moderna COVID-19 Vaccine, Bivalent Product (Aged 12 years and older) (Dark Blue Cap with gray border)[6] | $0.010[1] | Code not active during this time | 08/31/2022 – TBD[6] |
0134A | ADM SARSCV2 BVL 50MCG/.5ML B | Moderna | Moderna COVID-19 Vaccine, Bivalent (Aged 12 years and older) (Dark Blue Cap with gray border) Administration – Booster Dose[6] | $40.000[2] | Code not active during this time | 08/31/2022 – TBD[6] |
91314 |
SARSCOV2 VAC BVL 25MCG/0.25ML |
Moderna |
Moderna COVID-19 Vaccine, Bivalent Product (Aged 6 years through 11 years) (Dark Blue Cap with gray border) |
$0.010[1] |
Code not active during this time |
10/12/2022 – TBD |
0144A |
ADM SARSCV2 BVL 25MCG/.25ML B |
Moderna |
Moderna COVID-19 Vaccine, Bivalent (Aged 6 years through 11 years) (Dark Blue Cap with gray border) Administration – Booster Dose |
$40.000[2] |
Code not active during this time |
10/12/2022 – TBD |
91315 |
SARSCOV2 VAC BVL 10MCG/0.2ML |
Pfizer |
Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product (Aged 5 years through 11 years) (Orange Cap) |
$0.010[1] |
Code not active during this time |
10/12/2022 – TBD |
0154A |
ADM SARSCV2 BVL 10MCG/.2ML B |
Pfizer |
Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product (Aged 5 years through 11 years) (Orange Cap) Administration – Booster Dose |
$40.000[2] |
Code not active during this time |
10/12/2022 – TBD |
91316 |
SARSCOV2 VAC BVL 10MCG/0.2ML |
Moderna |
Moderna COVID-19 Vaccine, Bivalent Product (Aged 6 months through 5 years) (Dark Pink Cap and a label with a yellow box) |
$0.010[1] |
Code not active during this time |
12/08/2022 – TBD |
0164A |
ADM SRSCV2 BVL 10MCG/0.2ML B |
Moderna |
Moderna COVID-19 Vaccine, Bivalent (Aged 6 months through 5 years) (Dark Pink Cap and label with a yellow box) Administration – Booster Dose |
$40.000[2] |
Code not active during this time |
12/08/2022 – TBD |
91317 |
SARSCOV2 VAC BVL 3MCG/0.2ML |
Pfizer |
Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product (Aged 6 months through 4 years) (Maroon Cap) |
$0.010[1] |
Code not active during this time |
12/08/2022 – TBD |
0173A |
ADM SARSCV2 BVL 3MCG/0.2ML 3 |
Pfizer |
Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration - Third dose |
$40.000[2] |
Code not active during this time |
12/08/2022 – TBD |
M0201 |
Covid-19 vaccine home admin |
Home vaccine admin |
Covid-19 vaccine administration inside a patient's home; reported only once per individual home per date of service when only covid-19 vaccine administration is performed at the patient's home |
$35.50[2] |
Code not active during this time |
06/08/2021 - TBD
|
[1] Since we anticipate that providers, initially, will not incur a cost for the product, CMS will update the payment allowance at a later date. Providers should not bill for the product if they received it for free.
[2] These rates will also be geographically adjusted for many providers. For providers and suppliers with payments that are geographically adjusted by the methodology used by the Medicare Physician Fee Schedule (MPFS), files with the geographically adjusted payment rates for COVID-19 vaccine administration are included in the “Additional Resources” section below. Certain settings utilize other payment methodologies, such as payment based on reasonable costs. Starting January 1, 2023, we’ll also annually update the COVID-19 vaccine payment rates to reflect changes in costs related to administering preventive vaccines.
[3] Johnson & Johnson COVID-19 vaccine. On May 5, 2022, the FDA limited the authorized use of the Janssen COVID-19 vaccine.
[4] Administration booster codes should be billed for all applicable booster doses as approved and/or authorized by the FDA.
[5] On June 17, 2022, FDA authorized the 50MCG/0.5ML presentation of the Moderna COVID-19 Vaccine to provide primary series doses in individuals 6 years through 11 years of age in addition to the 3/29/2022 FDA authorization to provide booster vaccination doses in individuals 18 years and older.
[6] On October 12, 2022, the FDA authorized the Moderna bivalent product (dark blue cap with gray border) and its administration for use as a single booster dose in individuals 12 years through 17 years of age in addition to the 8/31/2022 FDA authorization as a single booster dose in individuals 18 years and older.
Payment Allowances and Effective Dates for COVID-19 Monoclonal Antibodies and their Administration During the Public Health Emergency:
HCPCS Code |
HCPCS Short Descriptor | Labeler Name | Vaccine/Procedure Name | National Payment Allowance Effective for Claims with DOS on or after 05/6/2021 | National Payment Allowance Effective for Claims with DOS through 05/5/2021 | Effective Dates |
---|---|---|---|---|---|---|
Q0220 Note: This product isn’t currently authorized[12] |
Tixagev and cilgav, 300mg |
AstraZeneca |
Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 300 mg |
$0.010[1] |
Code not active during this time period |
12/08/2021 - TBD |
Q0221 Note: This product isn’t currently authorized[12] |
Tixagev and cilgav, 600mg |
AstraZeneca |
Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 600 mg |
$0.010[1] |
Code not active during this time period |
02/24/2022 - TBD |
M0220 Note: This product isn’t currently authorized[12] |
Tixagev and cilgav inj |
AstraZeneca |
Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), includes injection and post administration monitoring |
$150.50[3] |
Code not active during this time period |
12/08/2021 - TBD |
M0221 Note: This product isn’t currently authorized[12] |
Tixagev and cilgav inj hm |
AstraZeneca |
Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), includes injection and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency
|
$250.50[3] |
Code not active during this time period |
12/08/2021 - TBD |
Q0222 Note: This product isn’t currently authorized[11] |
Bebtelovimab 175 mg |
Eli Lilly |
Injection, bebtelovimab, 175 mg |
$2394.00[1] [1a] |
Code not active during this time period |
02/11/2022 - TBD |
M0222 Note: This product isn’t currently authorized[11] |
Bebtelovimab injection |
Eli Lilly |
Intravenous injection, bebtelovimab, includes injection and post administration monitoring |
$350.50[3] |
Code not active during this time period |
02/11/2022 - TBD |
M0223 Note: This product isn’t currently authorized[11] |
Bebtelovimab injection home |
Eli Lilly |
Intravenous injection, bebtelovimab, includes injection and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency |
$550.50[3] |
Code not active during this time period |
02/11/2022 - TBD |
Q0239 |
Bamlanivimab-xxxx |
Eli Lilly |
Injection, bamlanivimab, 700 mg |
Code not active during this time period |
$0.010[1] |
11/10/2020 – 04/16/2021[4] |
M0239 |
Bamlanivimab-xxxx infusion |
Eli Lilly |
Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring |
Code not active during this time period |
$309.600[3] |
11/10/2020 – 04/16/2021[4] |
Q0240[6] |
Casirivi and imdevi 600mg |
Regeneron |
Injection, casirivimab and imdevimab, 600 mg |
$0.010[1] |
Code not active during this time period |
07/30/2021 – TBD |
M0240[6] |
Casiri and imdev repeat |
Regeneron |
Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring, subsequent repeat doses |
$450.00[3] |
Code not active during this time period |
07/30/2021 – TBD |
M0241[6] |
Casiri and imdev repeat hm |
Regeneron |
Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence, this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency, subsequent repeat doses |
$750.00[3] |
Code not active during this time period |
07/30/2021 – TBD |
Q0243 |
Casirivimab and imdevimab |
Regeneron |
Injection, casirivimab and imdevimab, 2400 mg |
$0.010[1] |
$0.010[1] |
11/21/2020 – TBD |
M0243 |
Casirivi and imdevi inj |
Regeneron |
Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring |
$450.00[3] |
$309.600[3] |
11/21/2020 – TBD |
Q0244[5] |
Casirivi and imdevi 1200 mg |
Regeneron |
Injection, casirivimab and imdevimab, 1200 mg |
$0.010[1] |
$0.010[1] |
06/03/2021 – TBD |
M0244 |
Casirivi and imdevi inj hm |
Regeneron |
Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency |
$750.00[3] |
Code not active during this time period |
05/06/2021 – TBD |
Q0245[8] |
Bamlanivimab and etesevima |
Eli Lilly |
Injection, bamlanivimab and etesevimab, 2100 mg |
$0.010[1] |
$0.010[1] |
02/09/2021 – TBD |
M0245[8] |
Bamlan and etesev infusion |
Eli Lilly |
intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring |
$450.00[3] |
$309.600[3] |
02/09/2021 – TBD |
M0246[8] |
Bamlan and etesev infus home |
Eli Lilly |
Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency |
$750.00[3] |
Code not active during this time period |
05/06/2021 – TBD |
Q0247[7] Note: This product isn’t currently authorized[10] |
Sotrovimab |
GSK |
Injection, sotrovimab, 500 mg |
$2394.00 |
Code not active during this time period |
05/26/2021 – TBD |
M0247 Note: This product isn’t currently authorized[10] |
Sotrovimab infusion |
GSK |
Intravenous infusion, sotrovimab, includes infusion and post administration monitoring |
$450.00[3] |
Code not active during this time period |
05/26/2021 – TBD |
M0248 Note: This product isn’t currently authorized[10] |
Sotrovimab inf, home admin |
GSK |
Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the covid-19 public health emergency |
$750.00[3] |
Code not active during this time period |
05/26/2021 – TBD |
Q0249[2] |
Tocilizumab for COVID-19 |
Genentech |
Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg |
$6.572 |
Code not active during this time period |
06/24/2021 - TBA |
M0249 |
Adm Tocilizu COVID-19 1st |
Genentech |
Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose |
$450.00[3] |
Code not active during this time period |
06/24/2021 - TBA |
M0250 |
Adm Tocilizu COVID-19 2nd |
Genentech |
Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose |
$450.00[3] |
Code not active during this time period |
06/24/2021 - TBA |
[1] Providers shouldn't bill for the product if they received it for free through the USG-purchased inventory.
[1a] Payment rate effective for dates of service on or after August 15, 2022. Providers should only bill Medicare for commercially-purchased products.
[2] Given the limited clinical situations allowed under the EUA, providers should only bill for tocilizumab on a 12x type of bill (TOB).
[3] These rates will be geographically adjusted for many providers. For providers and suppliers with payments that are geographically adjusted by the methodology used by the Medicare Physician Fee Schedule (MPFS), files with the geographically adjusted payment rates for monoclonal antibody administration are included in the “Additional Resources” section below. Certain settings utilize other payment methodologies, such as payment based on reasonable costs.
[4] On April 16, 2021, the FDA revoked the EUA that allowed for the investigational monoclonal antibody therapy bamlanivimab, when administered alone, to be used for the treatment of mild-to-moderate COVID-19 in adults and certain pediatric patients. As a result, Medicare won't pay for claims with HCPCS codes M0239 or Q0239 with dates of service after April 16, 2021.
[5] On June 3, 2021, the FDA revised the EUA for casirivimab and imdevimab to change the allowed dosing regimen from 2400 mg to 1200 mg, and allow providers to administer the combination product by subcutaneous injection in limited circumstances. As a result, CMS issued a new product code for casirivimab and imdevimab (Q0244) and updated the descriptors for the existing administration codes (M0243/M0244).
[6] On July 30, 2021, the FDA revised the EUA for casirivimab and imdevimab to allow its use for post-exposure prophylaxis (PEP) in certain adult and pediatric patients. For patients who meet the criteria for repeat dosing, the authorized dosage is an initial dose of 1200 mg, followed by subsequent repeat dosing of 600 mg once every 4 weeks for the duration of ongoing exposure. As a result, CMS issued a new product code for casirivimab and imdevimab of 600 mg (Q0240), and 2 new codes for the administration of repeat doses of casirivimab and imdevimab (M0240/M0241). Providers and suppliers who administer casirivimab and imdevimab for PEP should use M0243 or M0244 for administering the first dose and M0240 or M0241 for administering subsequent repeat doses.
[7] When the government provides monoclonal antibody products to treat COVID-19 for free, providers should only bill for the administration; don’t include the monoclonal antibody product codes on these claims. If you got the product for free, and your systems require a product code to bill for the administration, enter $0.01 for the billed amount.
[8] On September 16, 2021, the FDA revised the EUA for bamlanivimab and etesevimab, administered together, to allow its use for post-exposure prophylaxis (PEP) in certain adult and pediatric patients. Providers and suppliers should use Q0245 and M0245 or M0246 to bill for administering bamlanivimab and etesevimab for PEP.
[9] On January 24, 2022, the FDA announced that, due to the high frequency of the Omicron variant, REGEN-COV (casirivimab and imdevimab, administered together) isn’t currently authorized in any U.S region. Therefore, you may not administer REGEN-COV for treatment or post-exposure prevention of COVID-19 under the EUA until further notice.
[10] On April 5, 2022, the FDA announced that, due to the high frequency of the Omicron BA.2 sub-variant, sotrovimab isn’t currently authorized in any U.S. region. Therefore, you may not administer sotrovimab to treat COVID-19 under the EUA until further notice.
[11] On November 30, 2022, the FDA announced that bebtelovimab isn’t currently authorized in any U.S. region because it isn’t expected to neutralize Omicron sub-variants BQ.1 and BQ.1.1. Therefore, you may not administer bebtelovimab to treat COVID-19 under the EUA until further notice.
[12] On January 26, 2023, the FDA announced that EVUSHELD isn’t currently authorized for emergency use in the U.S.
Additional Resources:
Following links contain helpful information for providers. Product NDCs can be found in the EUA Fact Sheet for Healthcare Providers and can be used to identify the appropriate HCPCS codes for each product and its administration. NDC - HCPCS crosswalk is available in CMS ASP crosswalk zip folder. Long, medium, and short descriptors of COVID-19 CPT codes are available from AMA website.
COVID-19 CPT vaccine and immunization codes - AMA
COVID-19 Vaccination Resources at CDC
COVID-19 Vaccination Training Programs and Reference Materials for Healthcare Professionals
Information about Public Health Emergency
Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction
Quick reference guide to the coding structure for COVID-19 vaccine CPT reporting
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Geographically-adjusted Payment Rates
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Jan - Dec 2023 Geographically-adjusted Payment Rates for COVID-19 Vaccine Administration [For claims with dates of service 01/01/2023 through 12/31/2023]
Jan - Dec 2023 Geographically-adjusted Payment Rates for Monoclonal Antibody Administration [For claims with dates of service 01/01/2023 through 12/31/2023]
2022
Jan - Dec 2022 Geographically-adjusted Payment Rates for COVID-19 Vaccine Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) *Updated 12/20/2022 to reflect the new codes for Moderna and Pfizer-BioNTech pediatric bivalent (updated COVID-19 vaccines) booster dose/
Jan - Dec 2022 Geographically-adjusted Payment Rates for Monoclonal Antibody Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) *Updated 02/17/2022 to reflect the new codes for bebtelovimab [For claims with dates of service 02/11/2022 through 12/31/2022]
2021
Jan - March 2021 Geographically-adjusted Payment Rates for COVID-19 Vaccine Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) *Updated February 16, 2021 for addition of the COVID-19 Janssen vaccine* [For claims with dates of service of 1/1/2021 through 3/14/2021]
March - Dec 2021 Geographically-adjusted Payment Rates for COVID-19 Vaccine Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) *Updated 11/02/2021 to account for effective dates for Pfizer-BioNTech COVID-19 Pediatric Vaccine [For claims with dates of service 3/15/2021 through 12/31/2021]
Jan-May 2021 Geographically-adjusted Payment Rates for Monoclonal Antibody Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) [For claims with dates of service of 1/1/2021 through 5/5/2021]
May-Dec 2021 Geographically-adjusted Payment Rates for Monoclonal Antibody Administration (for Providers & Suppliers Paid MPFS-Adjusted Rates) (ZIP) *Updated 12/23/2021 to account for new codes for tixagevimab co-packaged with cilgavimab* [For claims with dates of service 5/6/2021 through 12/31/2021]
2020
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Monoclonal Antibody Emergency Use Authorizations (EUAs) & Fact Sheets
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- ACTEMRA® (tocilizumab): EUA and EUA Fact Sheet for Healthcare Providers
- Bamlanivimab: EUA and EUA Fact Sheet for Healthcare Providers
- Bamlanivimab and etesevimab: EUA and EUA Fact Sheet for Healthcare Providers
- Bebtelovimab: EUA and EUA Fact Sheet for Healthcare Providers
- EvusheldTM (tixagevimab co-packaged with cilgavimab): EUA and EUA Fact Sheet for Healthcare Providers
- REGEN-COV® (casirivimab and imdevimab): EUA and EUA Fact Sheet for Healthcare Providers
- Sotrovimab: EUA and EUA Fact Sheet for Healthcare Providers
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Vaccine Authorization Letters & Fact Sheets
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- Janssen COVID-19 vaccine: Authorization Letter and Fact Sheet for Healthcare Providers
- Moderna COVID-19 vaccine: Authorization Letter and Fact Sheet for Healthcare Providers
- Novavax COVID-19 vaccine, adjuvanted: Authorization Letter and Fact Sheet for Healthcare Providers
- Pfizer-BioNTech COVID-19 vaccine: Authorization Letter and Fact Sheets for Healthcare Providers