NYS Medicaid Program Pharmacists as Immunizers Fact Sheet
Effective October 15, 2009, the administration of select vaccines by qualified pharmacists employed by, or under contract with, Medicaid enrolled pharmacies will be reimbursable under NYS Medicaid. Administration of vaccines will be conducted pursuant to NYS Education Law and regulations (8NYCRR63.9) which permits licensed pharmacists who obtain additional certification to administer influenza and pneumococcal vaccinations to adults 18 years of age and older.
The following conditions will apply:
- Only Medicaid enrolled pharmacies that employ or contract with NYS certified pharmacists to administer vaccines will receive reimbursement for immunization services and products. Each pharmacist certified to administer immunizations will receive a new registration certificate that will contain the prefix "I". Pharmacy interns cannot administer immunizations in New York State.
- Services must be provided and documented in accordance to NYS Department of Education laws and regulations. Visit http://www.op.nysed.gov/pharmimmunizations.htm for additional information.
- Pharmacies will only be able to bill for Medicaid fee-for-service enrollees. Medicaid managed care and Family Health Plus enrollees will continue to access immunization services through their health plans.
- Reimbursement will be based on a patient specific 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.
- Consistent with Medicaid immunization policy for practitioners, pharmacies will bill the administration and cost of the vaccine using the following procedure codes. Please note that NDCs are not to be used for billing the vaccine product. Reimbursement for the product will be made at no more than the actual acquisition cost to the pharmacy. No dispensing fee or enrollee co-payment applies.
Procedure Code Procedure Description 90656 Seasonal Influenza virus vaccine, preservative free, for intramuscular use 90658 Seasonal Influenza virus vaccine, for intramuscular use 90660 Seasonal Influenza, live, for intranasal use 90732 Pneumococcal vaccine, for intramuscular use 90663* Influenza A (H1N1) vaccine, all forms G0008 Administration of seasonal influenza virus vaccine, intramuscular use 90473 Administration of seasonal influenza intranasal vaccine G0009 Administration of pneumococcal vaccine 90470 Administration of influenza A (H1N1) vaccine - The following chart describes the codes and fees that are reimbursable to pharmacies.
| Immunization Type | CPT Code For Vaccine | CPT Code for Administration | Amount Paid for Vaccine | Amount Paid for Administration |
|---|---|---|---|---|
| Age 18 and older | ||||
| Seasonal Flu | 90656 90658 90660 | G0008 for intramuscular administration 90473 for intranasal or oral administration | Actual Acquisition Cost | $13.23 $8.57 |
| Pneumococcal | 90732 | G0009 for intramuscular administration | Actual Acquisition Cost | $13.23 |
| H1N1 | 90663 (Does not need to be reported) | 90470 for any route of administration | $0* (vaccine supplied for free) | $13.23 |
* Please note that the H1N1 vaccine is being provided free by the Centers for Disease Control and Prevention. Therefore, while administration of the H1N1 vaccine is reimbursable by Medicaid, the vaccine product itself is not.
Questions regarding Medicaid reimbursement of immunizations may be directed to the Medicaid Pharmacy Program at 518 486-3209 or PPNO@health.state.ny.us.
Additional information on influenza can be found at NYS Department of Health's website at
http://nyhealth.gov/diseases/communicable/influenza/.
