Submitting Pharmacy Claims for COVID-19 Vaccinations

Horizon Blue Cross Blue Shield of New Jersey and Horizon NJ Health will align with the Centers for Medicare & Medicaid Services’ (CMS) guidelines for the billing and reimbursement of COVID-19 vaccines and administration.

Currently, the federal government is covering the cost of the COVID-19 vaccine. There is no cost sharing for the administration of the vaccine for members when administered according to the Centers for Disease Control and Prevention’s guidelines. Members should not be billed. Horizon covers the cost of all health care professionals administering the vaccine without cost sharing (copays, deductibles, coinsurance) for commercial members regardless of whether or not the vaccine is administered by a health care professional in the Horizon network. Coverage without cost sharing regardless of whether or not the health care professional is in network will continue until the end of the federal public health emergency (which remains in effect), at which time Horizon will continue to cover the COVID-19 vaccine without cost sharing only when administered by an in-network health professional.

Claim Submission

To submit claims for eligible Horizon members, all pharmacies administering COVID-19 vaccines must:

• Meet state and federal regulations for receiving and administering vaccines.

• Follow the CDC’s Advisory Committee on Immunization Practices’ (ACIP) clinical guidelines for vaccine administration.

Claim Billing

• Please bill only for the vaccine administration. When vaccines become available for direct purchase by providers, updated guidelines will be provided.

• Please submit claims for vaccine administration through the member’s pharmacy benefit and follow National Council for Prescription Drug Programs (NCPDP)

• For Medicare, please submit claims for COVID-19 vaccine administration to Original Medicare through your Medicare Administrative Contractor (MAC).

Per NCPDP guidelines, pharmacies should include the following codes when billing for:

The Single Dose Vaccine and for the Initial Dose of Multi-Dose Vaccines:

The Second Dose of Multi-Dose Vaccines:

The Third Dose of Multi-Dose Vaccines:

Pharmacy COVID-19 Administration Fees:

Horizon will reimburse pharmacies for the administration of COVID-19 vaccines to eligible members at the below rates.

Participating pharmacies that have ancillary service agreements with Horizon:

The August 2021 update to your fee schedule will include the information below. Please continue to submit claims through the members’ pharmacy benefit.

Stay up to date.

Horizon will continue to reassess billing codes and reimbursement rates for vaccine administration costs and communicate any updates to you.

Questions?

For Commercial/Medicare inquiries, please email John Thornton at John_Thornton@HorizonBlue.com.

For Horizon NJ Health inquiries, please call our Pharmacy Help Desk at 1-800-682-9094, ext. 81016, weekdays, 8 a.m. to 6 p.m. Eastern Time (ET), and Saturday, 8 a.m. to 4:30 p.m. ET.