Premera Blue Cross Blue Shield of Alaska Response to COVID-19

New bivalent boosters are available from Moderna and Pfizer. The current monovalent boosters should only be used in children who are too young to receive one of the bivalent boosters.

• A Pfizer-BioNTech monovalent vaccine is authorized for children 6 months-11 years and a Moderna vaccine was authorized for children 6 months-17 years.
• Children need a 3-dose Pfizer primary series or a 2-dose Moderna primary series.
• A new Noravax booster vaccine dose was authorized for people ages 18 and older. New codes apply. 
• A new Moderna bivalent booster vaccine dose was authorized for people ages 12 and older. New codes apply.

Janssen (Johnson & Johnson) COVID-19 vaccine is authorized for adults ages 18 years and older in certain limited situations due to safety considerations. For guidance on respective record review, scheduling, and administration of the Janssen vaccine, view the CDC Interim Clinical Considerations for Use of COVID-19 Vaccines: Appendices, References, and Previous Updates.

o Pfizer-BioNTech vaccines are available to children ages 5-17. A Moderna vaccine is available for children ages 6-17. A Moderna booster vaccine dose was authorized for children ages 6-17. This is in addition to the Pfizer booster dose already authorized for children 5-17.
o A Pfizer-BioNTech vaccine was authorized for children 6 months to 4 years and a Moderna vaccine was authorized for children 6 months to 5 years. Children need a 3-dose Pfizer primary series or a 2-dose Moderna primary series.

If your child turns 12 between the first and second doses of the vaccine, the CDC is recommending they receive the full regular dose for their second shot. 

As a result of the ongoing COVID-19 public health emergency, the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC/NCHS) has implemented an additional code, U09.9 - post COVID-19 condition, unspecified. 

This code became effective October 1, 2021, to identify conditions following acute COVID-19. It's a secondary diagnosis code added after the specific condition related to COVID-19 is known, such as chronic respiratory failure, loss of smell, loss of taste, multisystem inflammatory syndrome, pulmonary embolism, pulmonary fibrosis etc. This code is not used in cases that are still presenting with active COVID-19 but it conditions which are the consequence of COVID-19.

View the CDC's ICD-10-CM coding guidance.

The CDC, and many medical practitioners, are strongly recommending everyone get a flu shot this year. With the flu almost non-existent last year due to the stay-at-home orders, masking and handwashing, many are expecting this flu season to come back strongly. According to the CDC, it is safe to get both your COVID-19 vaccine and the flu vaccine at the same time.

Yes. For commercial plans, to receive/administer COVID-19 vaccine, constituent products, and ancillary supplies, vaccination provider facilities/organizations must enroll in the federal COVID-19 Vaccination Program coordinated through their jurisdiction's immunization program. Enrolled COVID-19 vaccination providers must be credentialed/licensed in the jurisdiction where vaccination takes place, and sign and agree to the conditions in the CDC COVID-19 Vaccination Program Provider Agreement. These conditions are detailed in the agreement itself.

Each state has developed a draft plan for COVID-19 Vaccine preparedness (Washington & Alaska) addressing a variety of topics. That includes phases of distribution and allocation, identification of critical populations and initial plan for prioritization of administration to different groups.

If you want to enroll in your state Medicaid program as well, reach out to your representative from the State Medicaid Agency Provider Enrollment Contact List.

Alaska has developed a draft plan for COVID-19 Vaccine preparedness addressing a variety of topics. That includes phases of distribution and allocation, identification of critical populations and initial plan for prioritization of administration to different groups.

These codes must be used for the Pfizer, Moderna, and Johnson & Johnson vaccines. Use the links below to ensure the new codes are in your system to facilitate efficient claims processing.

COVID-19 Vaccine codes (medical)
Primary vaccines

Booster doses

Bivalent booster doses

Get the most up to date list of billing codes, payment allowances and effective dates.

If you're having difficulty billing for the COVID vaccine, contact the Express Scripts help desk at 800-922-1557.

Information about vaccines and distribution will continue to evolve.

For general questions about COVID-19 vaccines and vaccine trials, and for the CDC playbook:

• Centers for Medicare and Medicaid Services (CMS)
• Centers for Disease Control and Prevention (CDC)

The cost of the actual vaccine is being covered by the government for non-Medicare plans beginning January 1, 2022. The cost of administering the vaccine will be covered by insurers, like Premera. CMS has recently released expected costs for vaccine administration. We expect the vaccines will be billed by dose, similar to how other 2-dose vaccines are billed.

The new drugs being offered to treat COVID-19 (including Evusheld) currently covered under our policy as emergency use authorization (EUA) drugs may be accepted per policy 05.01.549: Off-label Use of Drugs and Biologic Agents. (Please note: These drugs are covered under mandate and the public health emergency (PHE) and could change.) 

While Premera may not cover this drug in certain circumstances, it is not restricted at this time when acquired through government distribution systems.  When this drug is FDA approved, it is likely that Premera may institute a medical policy with specific criteria on use of this drug. 

Additionally, coding on administration of these drugs are guided by CMS administration codes.  

Because these drugs are approved only through EUA, our stance on this drug could change based on the PHE changes, FDA approval status, or additional data as it becomes available. 

Test-to-treat antivirals began distribution by HHS on March 7, 2022. Oral antivirals may only be provided when prescribed by a qualified healthcare provider. Only pharmacies with in-store clinics are eligible for distributing these medications. Get more information and find a test-to-treat location.

President Joe Biden laid out his strategy to fight the Omicron and Delta coronavirus variants over the winter, which included insurer-funded at-home COVID-19 testing. The rules regarding health plan reimbursement for self-tests purchased by consumers were made available on January 10, 2022. This mandate applies to all commercial plans.

Eligible tests are those with full FDA or EUA authorization and designated as home tests (antigen or molecular approved tests) used for diagnostic purposes (e.g., symptoms or direct exposure). Tests for surveillance purposes such as work or travel continue to be not covered. We will apply the quantity limit of 8 individual tests (not package) per covered member per 30 rolling days. These tests are not available for members with Medicare plans.

You can also order kits directly from the federal government at covidtests.gov (limited to 4 tests per household).

The new Families First Coronavirus Response Act requires all group health plans, including self-funded plans, to provide coverage for provider-ordered testing, including U.S. Food and Drug Administration (FDA)-approved COVID-19 diagnostic testing products and items and services related to testing furnished during an office, telehealth, urgent care center or emergency room visit. We have removed the group waivers that were previously in place to comply with this mandate.

Premera follows state and federal mandates related to end dates for these services. See the COVID-19 Key Dates section in this FAQ for current dates.

Commercial and Medicare Supplement members: We're waiving in-network cost shares (coinsurance, copays, and deductibles) for members requiring provider-ordered COVID-19 and influenza testing. All other treatments and services including hospitalization not related to a COVID-19 diagnosis will be subject to the usual benefits and cost shares.

Pre-authorization isn't required for provider-ordered COVID-19 testing. If a member requires COVID-19 testing and treatment and there isn't an in-network provider within a reasonable distance, the claims will be paid as in-network.

Premera's Benefit Coverage Guideline is effective for serology tests for dates of service July 1, 2020 and forward. Premera will reimburse for serology tests that are for the purpose of supporting a COVID-19 diagnosis as part of the treatment or management of a patient's medical condition.

Serological tests will not be covered when provided as the sole basis of diagnosis for current infection with COVID-19.

Cost share waivers for all COVID-19 related treatment (both inpatient and outpatient) ended on June 30, 2021. Treatment costs are still covered as a medical expense. Cost share waivers for COVID-19 diagnostic testing and related provider visit remain in place.

See the COVID-19 Key Dates section in this FAQ for current dates. You can check eligibility and benefits on our website.

S.B. 241 is a comprehensive coronavirus-related bill that assumes firefighters, emergency medical technicians, paramedics, peace officers, or health care providers who contract COVID-19 during the public health emergency declared on March 11 is presumed to have contracted it during employment.

When a member of this group seeks care, they should notify you they believe they contracted COVID-19 in the course of their job. You then codes the claim and submit as a workers' compensation claim. Premera pends the claim and asks the member to complete an incident questionnaire to obtain the worker's compensation information.

Any member that is presumed COVID-19 with these job titles must file a claim with the appropriate workers' compensation carrier; this could be Office of Worker's Compensation or their Self-Funded Compensation Carrier. The claim will either be processed by workers' compensation or by Premera, depending on the results of the incident questionnaire.

The following summary of coding instruction is provided by the CDC, the World Health Organization (WHO), and CMS related to COVID-19. We urge you to use this COVID-19 diagnosis and procedure coding for patients so cost shares may be waived appropriately.

There are two new HCPCS codes for lab tests to detect COVID-19: Code U0001 for the CDC test panel and code U0002 for other tests. In addition, two additional COVID test HCPCS codes U0003/U0004 for high throughput technologies are covered.

The American Medical Association added a new CPT code for reporting the novel coronavirus tests: 87635: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique.

Per the CDC, a new ICD-10 emergency code, U07.1, 2019-nCoV acute respiratory disease, has been established by the WHO for reporting the virus, effective with the next update, October 1, 2020. Premera is accepting this code and encourages you to use it.

To identify patients in the interim who've tested positive for COVID-19, current CDC guidance instructs to code first for the presenting illness followed by B97.29 - Other coronavirus, as the cause of diseases classified elsewhere.

For the new serology tests, the AMA created new CPT lab test codes: 86328 and 86769. Use these codes when submitting a claim for the antibody test.

As of January 1, 2021, new specific diagnosis codes must be used for all claims related to COVID-19 testing, treatment, and vaccines.
You can learn more about the codes through the following Centers for Disease Control (CDC) resources:
CDC: New COVID-19 ICD-10 Codes Effective January 1, 2021
One-page announcement of further additions to ICD-10 codes.
CDC: New COVID-19 Official Coding Guidelines
Chapter-specific coding guidelines, pages 28-33.

Premera is not required under either state or federal law to provide coverage for  return-to-work testing or occupational testing. We will not cover testing for occupational or accommodation purposes when an employee has an approved vaccine mandate accommodation from their employer. Premera also doesn't cover return-to-school or any travel-related testing. Federal and state law do not require that these tests be reimbursed as part of a health plan.

Tests done for return to work or school, travel, or purposes other than diagnosing when a patient has symptoms or exposure, may not be coded as diagnostic and may not be billed to the plan. These tests are strictly member liability. FEP and some self-funded plans are covering testing for travel. You can check eligibility and benefits on our provider website.

Yes. For Premera-contracted providers, your current contract covers telehealth services if the care provided is appropriate within the scope of the provider's licensure. This change applies to Premera's individual and commercial members. However, some self-funded employer groups don't cover virtual care, so be sure to check your patient's benefits before providing care.

Note: Telehealth services aren't coded like in-office visits due to different modifiers and place of service codes needed to identify a telehealth service. There are additional codes that can be used for online video encounters as well as telephone visits in conjunction with the office visit codes.

Refer to your Premera contract for allowable information for virtual care codes. For specific coding information for Premera patients, see our telehealth payment policy for Alaska.>

For dental providers: You may bill the following visit types via tele-dentistry adding tele-dentistry modifier code of D9995/6:

• D0140 - Limited Oral Evaluation – Problem Focused
• D0170 - Re-evaluation, limited problem focused (established patient, not post-operative visit): This code is appropriate when assessing a previously existing condition related to trauma, or a follow-up evaluation for continuing issues
• D0190 – Screening of a patient. A screening, including state or federally mandated screenings, to determine an individual's need to be seen by a dentist for a diagnosis.
• This temporary modification becomes policy on April 1, 2021.

Premera wants to emphasize that this is a temporary relaxation of the rules during this nationwide public health emergency. Correct coding and notification to the patient that the provider is using non-HIPAA compliant communication tools is required.

Refer to your Premera contract for allowable information for virtual care codes. For specific coding information for Premera patients, see our telehealth payment policy for Alaska.

For providers delivering services via telehealth, Premera will require providers to continue use the correct telehealth place of service (POS) 02 with the procedure code appended with either modifier 95 or GT. Claims with modifiers indicating they were telehealth, if billed with POS 11, will be rejected up front and will require the correct POS to match the service billed. We will no longer accept POS 11 for telehealth services.

Refer to your Premera contract for allowable information for virtual care codes. For specific coding information for Premera patients, see our telehealth payment policy for Alaska.