MedicaidBilling CodesMedium impact
Instructions for COVID-19 Vaccine for Children Age 5-11 Years
Illinois Medicaid - HFS·IL · Pharmacy, Pediatrics·Provider Notice
Effective date
Oct 29, 2021
We identified it
Jun 20, 2026
Summary
Illinois Medicaid now covers COVID-19 vaccines for children ages 5-11 with specific NCPDP billing requirements. Pharmacies can bill $42.14 administration fees per dose using specific submission codes, with claims accepted retroactively from October 29, 2021.
Action Required
Immediately: Pharmacy billing teams must update NCPDP claim submission procedures for pediatric COVID-19 vaccines. Set Basis of Cost Determination to '15', Ingredient Cost to $0.00, Professional Service Code to 'MA', Days Supply to '1', and submit $42.14 administration fee in Incentive Amount field. Use Submission Clarification Code '02' for first dose and '06' for second dose. Enter prescriber NPI or use pharmacist NPI with SCC '42' and Prescription Origin Code '5'.