NYS Medicaid FFS Program

  • Fact Sheet is also available in Portable Document Format (PDF)

Pharmacists as Immunizers Fact Sheet

(Update September 2020)

In accordance with New York State (NYS) Education Law, NYS Medicaid members can obtain the following vaccines when administered to patients 18 years of age and older. Zoster, pneumococcal, meningococcal, tetanus, diphtheria, and pertussis vaccines. For patients 2 years of age and older, influenza vaccines may be administered at a Medicaid enrolled pharmacy.The following conditions apply:

  • Only Medicaid enrolled pharmacies, in accordance with NYS Education law will receive reimbursement for immunization services and products. Services must be provided and documented in accordance to NYS Education laws and regulations, including the reporting of all immunizations administered to members less than 19 years of age to either the State Department of Health using the NY 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) members will continue to access immunization services through their health plans. For Medicaid Managed Care Organization (MCO) billing guidance please contact the plan. Individual plan information can be found here. Click on the individual plan for "Pharmacy Vaccine Billing Guidance."
  • 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. The ordering prescriber's NPI is required on the claim for the claim to be paid.
  • Vaccines recommended by the Advisory Committee on Immunization Practices (ACIP)-recommended vaccines for individuals under the age of 19 are provided to Medicaid members (both FFS and MCO) free of charge by the Vaccines for Children (VFC) program.
    • Pharmacies wishing to administer VFC-available vaccines to Medicaid members under 19 years of age may enroll in the VFC program. Note: The VFC program is currently enrolling pharmacies to receive influenza vaccine only. Pharmacies immunizing members 18 years of age with pneumococcal, meningococcal, tetanus, diphtheria and pertussis vaccines may not bill Medicaid for the costs of these vaccines. Members 18 years of age who are enrolled in Medicaid are VFC-eligible and may receive these vaccines through a VFC healthcare practice or clinic.
    • NYS Medicaid should neverbe billed for the cost of any vaccine for persons under 19 years of age when it is available through the VFC Program. This applies to both FFS and MMC. Pharmacies that bill Medicaid for the cost of vaccines when it is 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 under 19 years of age at no charge to the member or Medicaid program, and be reimbursed an immunization fee of $17.85 by NYS Medicaid.
    • Additional information on the VFC Program, based on location, can be found at the following links:

Billing Instructions for FFS:

  • 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 at: https://www.emedny.org/ProviderManuals/Pharmacy/PDFS/Pharmacy_Fee_Schedule.xls
  • Please note: National Drug Codes (NDCs) are not to be used for billing the vaccine product Medicaid FFS. Reimbursement for the cost of the vaccine for members 19 years of age and older will be made at no more than the actualacquisition 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 NCPDP D.0 format

NCPDP D.0. Claim Segment Field Value
436-E1 (Product/Service ID Qualifier) value of "09" (HCPCS), 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 2 and/or 3. Up to 4 claim lines can be submitted with one transaction.
  • 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 of Members 19 Years of Age and Younger:

  • 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") that 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 new edit 02291.
  • For National Council for Prescription Drug Programs (NCPDP) claims transactions that are denied for edit 02291, the corresponding Medicaid Eligibilility 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 in the table below should be billed for select influenza for ages 2 and over; pneumococcal and meningococcal vaccines for age 18 and over; and zoster for age 50 and over:

Procedure Code Procedure Description
90620 Meningococcal recombinant protein and outer membrane vesicle vaccine, Serogroup B, 2 dose schedule, for intramuscular use
90621 Meningococcal recombinant lipoprotein vaccine, Serogroup B, 2 or 3 dose schedule, for intramuscular use
90653 Influenza virus vaccine (IIV), preservative free, for use in individuals 65 years of age and above, for intramuscular use
90656 Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years of age and above, for intramuscular use
90658 Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use
90661 Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
90662 Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use
90670 Pneumococcal conjugate vaccine, 13-valent, for intramuscular use
90672 Influenza virus vaccine, quadrivalent, live, for intranasal use in individuals 2 years of age through 49
90673 Influenza virus vaccine, trivalent, derived from recombinant DNA, preservative free, for intramuscular use for 18 years of age and older
90674 Influenza virus vaccine; quadrivalent, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
90682 Influenza virus vaccine, quadrivalent, (RIV4), derived from recombinant DNA, preservative and antibiotic free for intramuscular use
90686 Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use
90688 Influenza virus vaccine, quadrivalent, split virus, when administered to 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 above, preservative free, for intramuscular use
90714 Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for use in individuals seven years or older, for intramuscular use
90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), for use in individuals 7 years or older, for intramuscular use
90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years of age or older, for subcutaneous or intramuscular use
90733 Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use, age 2 years of age and older
90734 Meningococcal conjugate vaccine, Serogroups A,C,Y and W-135 (trivalent), for intramuscular use, age 11 through 55
90736 Zoster (shingles) Vaccine, live, for subcutaneous injection, age 50 and older
90750 Zoster (shingles) Vaccine, age 50 and older for intramuscular use
90756 Influenza virus vaccine, quadrivalent, antibiotic free, for intramuscular use

The following procedure codes in the table below should be used for the actual administration of the vaccines listed above by a pharmacist:

Procedure Code Procedure Description
90473 Immunization administration of seasonal influenza intranasal vaccine for ages 19 and above $8.57
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) $13.23
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) $13.23
90460 Immunization administration of free vaccine through VFC Program for ages under 19 years $17.85

Providers should check the Pharmacy Provider manual at: https://www.emedny.org/ProviderManuals/Pharmacy/index.aspx for updated on the procedure codes found in the tables above for vaccines, under "OTC" and "Supply Fee Schedule."

Contact Information:

  • Contact the eMedNY Call Center at (800)343–9000 for questions regarding FFS billing.
  • Contact the individual managed care plan for questions regarding MCO billing. Individual plan information can be found at: https://mmcdruginformation.nysdoh.suny.edu/. Click on the individual plan for "Pharmacy Vaccine Billing Guidance."

Additional Resources: