Medicare updates payment for new Novavax COVID-19 vaccine

On October 3, the Food and Drug Administration amended the emergency use authorization of the adjuvanted Novavax COVID-19 vaccine to include the new 2023–2024 formula. This updated monovalent vaccine:

• Addresses currently circulating variants to provide better protection against serious consequences of COVID-19, including hospitalization and death,
• Includes the spike protein from the SARS-CoV-2 omicron variant lineage XBB.1.5

In response, the Centers for Medicare & Medicaid Services (CMS) updated the Medicare national payment allowance to $148.20 for CPT code 91304, “Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, 5 mcg/0.5 mL dosage, for intramuscular use,” which includes the adjuvanted Novavax Covid-19 vaccine for ages 12 years and older. Effective Oct. 3, Medicare no longer pays for the following Novavax COVID-19 vaccine administration codes:

• 0041A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage; first dose
• 0042A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage; second dose
• 0044A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage; booster dose

The federal government is no longer purchasing these Novavax products, which were engineered to fight previous versions of the virus. Instead, for administration of any approved COVID-19 vaccine product (Pfizer, Moderna, or Novavax), use CPT code 90480, “Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, single dose. Medicare Part B pays for the vaccine product and its administration (for the vaccine, that’s 95% of the average wholesale price). Medicare provides additional payment when you administer the vaccine in the patient’s home and fully covers both the vaccine and administration at no cost to patients.

For more information, review the Medicare COVID-19 Vaccine Shot Payment webpage and the CMS vaccine pricing page.

— Kent Moore, AAFP Senior Manager, Payment Strategies

Posted on Oct. 10, 2023