New York State Medicaid Fee-for-Service Program
- Fact Sheet is also available in Portable Document Format (PDF)
Pharmacists as Immunizers Fact Sheet
(Updated 8/9/2023 - Updates are highlighted)
In accordance with New York State (NYS) Education law, pharmacists certified to administer immunizations are authorized to administer to patients 18 years of age and older, as recommended by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control and Prevention (CDC). The following vaccines can now be obtained by NYS Medicaid members, 18 years of age and older:
- COVID-19
- Hepatitis A
- Hepatitis B
- Herpes zoster (shingles)
- Human papillomavirus
- Influenza (2 years of age and older)
- Measles, mumps, and rubella
- Meningococcal
- Pneumococcal
- Respiratory syncytial virus
- Tetanus, diphtheria, and pertussis
- Varicella
NYS Medicaid coverage policy and billing guidance for the administration of COVID-19 vaccines can be found here. Please note: while the COVID-19 vaccines are still provided at no charge, the claim is billed as one single procedure code, with reimbursement for administration included in that code.
The following conditions apply:
- Only Medicaid-enrolled pharmacies will receive reimbursement for immunization services. Services must be provided and documented in accordance with state laws and regulations, including the reporting of all immunizations administered to persons less than 19 years of age to either the State Department of Health (DOH), using the New York State Immunization Information System (NYSIIS), or to the New York Citywide Immunization Registry (CIR). Additional information can be found here.
- Pharmacies will only be able to bill for Medicaid non-dual-eligible enrollees. Dual-eligible enrollees will continue to access immunization services through Medicare.
- Medicaid managed care (MMC) enrollees will continue to access immunization services through their NYRx at the pharmacy.
- Reimbursement for these vaccines may be based on a patient-specific order or non-patient specific order. These orders must be kept on file at the pharmacy. For patient-specific orders, the ordering prescriber´s National Provider Identification (NPI) is required on the claim for the claim to be paid.
- Vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) for individuals younger than 19 years of age are provided to Medicaid members, both fee-for-service (FFS) and MMC, free of charge by the Vaccines for Children (VFC) program.
- Pharmacies wishing to administer VFC-available vaccines to Medicaid members younger than 19 years of age may enroll in the VFC program. Note: The VFC program is currently enrolling pharmacies to receive the influenza vaccine only. Pharmacies immunizing patients 18 years of age with pneumococcal, meningococcal, tetanus, diphtheria and pertussis, hepatitis A, hepatitis B, human papillomavirus, measles, mumps, and rubella, and varicella vaccines may not bill Medicaid for the costs of these vaccines. Patients younger than 19 years of age, and enrolled in Medicaid, are VFC-eligible and may receive these vaccines through a VFC healthcare practice or clinic. Pharmacies that bill Medicaid for the cost of vaccines that are available through the VFC Program are subject to recovery of payment.
- Pharmacies that are not enrolled in the VFC program may choose to provide vaccines for members younger than 19 years of age, at no charge to the member or Medicaid program, and will be reimbursed an administration fee of $25.10 by NYS Medicaid.
- Additional information on the VFC Program, based on location, can be found at the following links:
Billing Instructions for NYRx:
Consistent with Medicaid immunization policy, pharmacies will bill the administration fee and, when applicable, acquisition cost of the vaccine using the appropriate procedure codes. Procedure codes can be found here.
Please note: National Drug Codes (NDCs) are not to be used for billing the vaccine product to Medicaid NYRx. Reimbursement for the cost of the vaccine for individuals 19 years of age and older will be made at no more than the actual acquisition cost to the pharmacy. No dispensing fee or enrollee co-payment applies. Pharmacies will bill with a quantity of "1" and a day supply of "1."
Vaccine claims submitted via the National Council for Prescription Drug Programs (NCPDP) D.0 format
| NCPDP D.0. Claim Segment Field | Value |
|---|---|
| 436-E1 (Product/Service ID Qualifier) | Enter value of "09" which qualifies the code submitted in field 407-D7 (Product/Service ID) as a procedure code. |
| 407-D7 (Product/Service ID) | Enter an applicable procedure code listed in Table B and/or C. Up to four claim lines can be submitted with one transaction. |
Please see the NYS Medicaid Pharmacy Manual Policy Guidelines document for further guidance on origin code and serial number values that must be submitted on the claim for "pharmacy dispensing" when applicable for non-patient specific orders.
NCPDP D.0 Companion guide can be found here.
Billing for Immunizations of Members 19 Years of Age and Older:
For administration of multiple vaccines on the same date to members 19 years of age and older, procedure code "90471" should be used for administration of the first vaccine and "90472" for administration of any other vaccines administered on that day. One line should be billed for "90472" indicating the additional number of vaccines administered (insert quantity of 1 or 2).
Billing for Immunizations for Members younger than 19 Years of Age:
For VFC-eligible vaccines, whether enrolled in the VFC Program or not, the pharmacy would submit procedure code "90460" (administration of free vaccine) for administration of first or subsequent doses, then submit the appropriate vaccine procedure code(s) with a cost of $0.00. A system edit will ensure that, when there is an incoming claim for the administrative fee (procedure code "90460"), there is also a claim in history for a VFC-eligible vaccine procedure code, reimbursed at $0.00. If no history claim is found, then the claim will be denied for the edit 02291.
For National Council for Prescription Drug Programs (NCPDP) claims transactions that are denied for edit 02291, the corresponding Medicaid Eligibility Verification System (MEVS) Denial Reason code "738" will be returned "History Not Found for Administrative Vaccine Claim" and NCPDP Reject code "85" "Claim Not Processed."
The following procedure codes should be billed for select influenza vaccines for those 2 years of age and older; pneumococcal, meningococcal, hepatitis A, hepatitis B, human papilloma virus, measles, mumps, and rubella, tetanus, diphtheria, and pertussis, respiratory syncytial virus, varicella, and zoster vaccines for those 18 years of age and older in accordance with ACIP recommendations:
| Procedure Code | Procedure Description |
|---|---|
| 90619 | Meningococcal conjugate vaccine, Serogroups A, C, W, Y, two dose schedule, for intramuscular use |
| 90620 | Meningococcal recombinant protein and outer membrane vesicle vaccine, Serogroup B, two dose schedule, for intramuscular use |
| 90621 | Meningococcal recombinant lipoprotein vaccine, Serogroup B, a two or three dose schedule, for intramuscular use |
| 90632 | Hepatitis A vaccine, adult dosage, for intramuscular use |
| 90633 | Hepatitis A vaccine, pediatric/adolescent dosage, 2 dose schedule, for intramuscular use |
| 90636 | Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use |
| 90651 | Human papillomavirus (HPV) vaccine, types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonvalent (9Vhpv), a 2 or 3 dose schedule, for intramuscular use |
| 90662 | Influenza virus vaccine (IIV4-HD), split virus, preservative free, enhanced immunogenicity via increased antigen content, for use in individuals 65 and above, for intramuscular use |
| 90670 | Pneumococcal conjugate vaccine (PCV13), 13-valent, for intramuscular use |
| 90671 | Pneumococcal conjugate vaccine (PCV15), 15-valent, for intramuscular use |
| 90672 | Influenza virus vaccine, quadrivalent (LAIV4), live, for use in individuals 2 years through 49 years of age, for intranasal use |
| 90674 | Influenza virus vaccine; quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, for use in individuals 2 years of age and older, for intramuscular use |
| 90677 | Pneumococcal conjugate vaccine (PCV20), 20-valent, for intramuscular use |
| 90678 | Respiratory syncytial virus vaccine, preF, subunit, bivalent, for intramuscular use |
| 90679 | Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use |
| 90682 | Influenza virus vaccine, quadrivalent, (RIV4), derived from recombinant DNA, preservative and antibiotic free, for use in individuals 18 years of age and older, for intramuscular use |
| 90685 | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for use in individuals 12 to 35 months, for intramuscular use |
| 90686 | Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, for use in individuals 3 years of age and older, for intramuscular use |
| 90687 | Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 dosage, for use in individuals 24 through 35 months of age, for intramuscular use |
| 90688 | Influenza virus vaccine, quadrivalent (IIV4), split virus, for use in individuals 3 years of age and older, with preservative, for intramuscular use |
| 90694 | Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, for individuals 65 years of age and older, for intramuscular use |
| 90707 | Measles, mumps, and rubella virus vaccine (MMR), live, for subcutaneous use |
| 90714 | Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for intramuscular use |
| 90715 | Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), for intramuscular use |
| 90716 | Varicella virus vaccine, live, for subcutaneous use |
| 90732 | Pneumococcal polysaccharide vaccine (PPSV23), 23-valent, adult, or immunosuppressed patient dosage, for subcutaneous or intramuscular use |
| 90734 | Meningococcal conjugate vaccine, Serogroups A, C, Y and W-135 (trivalent), for intramuscular use |
| 90739 | Hepatitis B vaccine, adult dosage, 2 dose schedule, for intramuscular use |
| 90740 | Hepatitis B vaccine, dialysis, or immunosuppressed patient, 3 dose schedule, for intramuscular use |
| 90744 | Hepatitis B vaccine, pediatric/adolescent dosage, 3 dose schedule, for intramuscular use |
| 90746 | Hepatitis B vaccine, adult dosage, 3 dose schedule, for intramuscular use |
| 90747 | Hepatitis B vaccine, dialysis, or immunosuppressed patient, 4 dose schedule, for intramuscular use |
| 90750 | Zoster (shingles) Vaccine, for use in individuals 19 years of age and older with immunocompromising conditions, for intramuscular use |
| 90756 | Influenza virus vaccine, quadrivalent (ccIIV4), antibiotic free, use in individuals 2 years of age and older, for intramuscular use |
| 90759 | Hepatitis B vaccine, for use in individuals 18 years of age and older, three dose schedule, for intramuscular use |
The following procedure codes below should be used for the actual administration of the vaccines listed above by a pharmacist.
| Procedure Code | Procedure Description |
|---|---|
| 90460 | Immunization administration of free vaccine through VFC Program for members younger than 19 years of age $25.10 |
| 90471 | Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) $13.36 |
| 90472 | Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure) $13.36 |
| 90473 | Immunization administration of seasonal influenza intranasal vaccine for ages 19 years and older $8.66 |
Vaccine Counseling:
Pharmacists offering vaccine counseling services to members 18 years of age or younger can reference the coverage and reimbursement policy outlined in the Early and Periodic Screening, Diagnostic, and Treatment Program Childhood Vaccine Counseling Coverage Benefit article published in the March 2022 issue of the Medicaid Update.
Billing Instructions for MMC Pharmacy Billing:
NYRx should be billed for any vaccine administered by a pharmacy provider. For non-pharmacy providers, individual MMC plans should be contacted for their specific reimbursement and billing guidance. Plan information can be found by visiting the following website.
Questions and Additional Information:
- Additional information on influenza is available on the NYS DOH web page, titled What You Should Know About the Flu.
- NYRx billing and claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
- NYRx Pharmacy coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
