New York State Medicaid Fee-for-Service Program:

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

Pharmacists as Immunizers Fact Sheet

(Update September 2021)

In accordance with New York State (NYS) Education Law, pharmacists are authorized to administer the following vaccines to patients 18 years of age and older: zoster, pneumococcal, meningococcal, tetanus, diphtheria, and pertussis vaccines. For patients two years of age and older, pharmacies may administer influenza vaccines. Additional information can be found on the NYS Education Department "Administration of Immunizations" web page.

Only Medicaid enrolled pharmacies will receive reimbursement for immunization services and products. Services must be provided and documented in accordance with NYS Education laws and regulations, including the reporting of all immunizations administered to members less than 19 years of age to either the NYS Department of Health (DOH), using the NY State Immunization Information System (NYSIIS), or to the New York City Department of Health and Mental Hygiene (NYC DOHMH) using the New York Citywide Immunization Registry (CIR).

Pharmacies will only be able to bill for Medicaid non-dual eligible members. Dual eligible members will continue to access immunization services through Medicare. Medicaid Managed Care (MMC) enrollees will continue to access immunization services through their health plans. For Medicaid Managed Care Organization (MCO) billing guidance, providers must contact the individual plan. Providers can access individual plan information via the NYS MMC Pharmacy Benefit Information Center web page, then select the individual plan and choose "Pharmacy Vaccine Billing Guidance".

Reimbursement for these vaccines may be based on a patient specific, or non-patient specific, order. These orders must be kept on file at the pharmacy. The ordering prescriber must be actively enrolled as a NYS Medicaid provider, unless otherwise exempt, and the prescribers National Provider Identifier (NPI) is required on the claim for the claim to be paid.

Vaccines for administration to individuals under the age of 19 are recommended by the Advisory Committee on Immunization Practices (ACIP) and are provided to Medicaid FFS members and MMC enrollees 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. Please note: The VFC program is currently enrolling pharmacies to receive the influenza vaccine only.
  • Pharmacies enrolled in the VFC program may submit claims to FFS and MMC for the administration fee for VFC-eligible vaccinations administered at the pharmacy.
  • 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/enrollee or Medicaid program, and be reimbursed an immunization fee of $17.85 by NYS Medicaid.
  • Pharmacies immunizing Medicaid members 18 years of age with pneumococcal, meningococcal, tetanus, diphtheria, and pertussis vaccines may not bill Medicaid for the costs of these vaccines, as these members are VFC-eligible such that they may receive these vaccines through a VFC healthcare practice or clinic.
  • NYS Medicaid should never be 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.

Additional information on the VFC Program, based on location, can be found at the following web pages:

Billing Instructions for Medicaid FFS

Consistent with Medicaid immunization policy, pharmacies may bill the vaccine administration fee and, when applicable, acquisition cost of the vaccine using the appropriate procedure codes. To view a list of procedure codes, providers can refer to the NYS Medicaid Pharmacy Services Fee Schedule.

Please note: National Drug Codes (NDCs) are not to be used for billing the vaccine product through 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 actual acquisition cost to the pharmacy. No dispensing fee or member co-payment applies. Pharmacies will bill with a quantity of "1" and a daily supply of "1".

Table A: 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.
442-E7 (Quantity Dispensed) Enter the value of "1" for the procedure administration code in Table B.
405-D5 (Day Supply) Enter the value of "1" .
411-DB (Prescriber ID) Enter Prescriber National Provider Number (NPI) number.
454-EK (Scheduled Prescription ID Number) Enter serial number "99999999" when applicable for non-patient specific orders.*
419-DJ (Prescription Origin Code) Enter origin code "5". *

*For further guidance on origin code and serial number values that must be submitted on the claim, refer to the Matching Origin Codes to Correct Prescription Serial Number Within Medicaid Fee-For-Service (FFS) article in the July 2016 issue of the Medicaid Update. For the origin code, "5" and the corresponding serial number of "99999999" for "Pharmacy dispensing" is to be used for applicable non-patient specific orders. The NCPDP D.0 Companion Guide can be found on the eMedNY "5010/D.0 Transaction Instructions" web page.

Billing for Immunizations of Members 19 Years of Age and Older

For billing of administration of multiple vaccines on the same date to members 19 years of age and older, procedure code "90471" should be used for the first vaccine and "90472" for any other vaccines administered on that day. One line should be billed for "90472" indicating the additional number of vaccines administered (insert quantity of one or two).

Billing for Immunizations of Members 19 Years of Age and Younger

For VFC-eligible vaccines, regardless of enrollment in the VFC Program, the pharmacy would submit procedure code "90460" (administration of free vaccine) for administration of first or subsequent dose and 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, the claim will be denied for edit "02291". For NCPDP claim transactions that are denied for edit "02291", the corresponding Medicaid Eligibility Verification System (MEVS) Denial Reason Code "738" History Not Found for Administrative Vaccine Claim will be returned as well as the NCPDP Reject code "85", Claim Not Processed.

Table B: The following procedure codes below should be billed for select influenza vaccines for ages two years of age and over; pneumococcal and meningococcal vaccines for 18 years of age and over; and zoster for 50 years of age 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
"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 two years of age through 49
"90674" Influenzavirus vaccine; quadrivalent, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use
"90682" Influenza virus vaccine, quadrivalent, quadrivalent recombinant influenza vaccine (RIV4), derived from recombinant deoxyribonucleic acid (DNA), preservative and antibiotic free for intramuscular use
"90686" Influenza virus vaccine, quadrivalent, split virus, preservative free, when administered to individuals three years of age and older, for intramuscular use
"90688" Influenza virus vaccine, quadrivalent, split virus, when administered to individuals three 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 seven years or older, for intramuscular use
"90732" Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals two years of age or older, for subcutaneous or intramuscular use
"90733" Meningococcal polysaccharide vaccine [any group(s)], for subcutaneous use, age two years of age and older
"90734" Meningococcal conjugate vaccine, Serogroups A, C, Y and W-135 (trivalent), for intramuscular use, age 11 through 55
"90750" Zoster (shingles) Vaccine, age 50 and older for intramuscular use
"90756" Influenza virus vaccine, quadrivalent, antibiotic free, for intramuscular use

Table C: The following procedure codes 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); one 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

For additional information on the procedure codes for vaccines found in the tables above, refer to the OTC and Supply Fee Schedule document on the eMedNY "Pharmacy Manual" web page.

Questions and Additional Information:

  • Medicaid FFS billing/claims questions should be directed to the eMedNY Call Center by phone at (800) 343-9000.
  • MMC enrollment, reimbursement, billing, and/or documentation requirement questions should be directed to the MMC enrollee´s specific MMC Plan. Providers can access individual plan information via the NYS "MMC Pharmacy Benefit Information Center" web page, then select the individual plan and choose "Pharmacy Vaccine Billing Guidance".
  • Additional information on influenza can be found on the NYS DOH "What You Should Know About the Flu" web site.
  • Additional vaccine and immunization information can be found on the CDC "Vaccine and Immunizations" web page.
  • Additional information on the pharmacy administration of immunizations can be found on the NYS Education Department "Administration of Immunizations" web page.
  • NYS Medicaid coverage policy and billing guidance for COVID-19 vaccine administration can be found within the NYS Medicaid Coverage Policy and Billing Guidance for the Administration of COVID-19 Vaccines Authorized for Emergency Use.