New York State Medicaid Fee-for-Service Program

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Pharmacists as Immunizers Fact Sheet

(Updated December 29, 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.

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.
    • Note: certain vaccines may be ordered by a pharmacist, outside of a standing order, in accordance with the PREP Act until December 31, 2024. Please see the NYS Medicaid Pharmacy Manual Policy Guidelines section titled, Non-Patient Specific Drug Orders for guidance related to processing these orders.
  • Vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) for individuals younger than 19 years of age are provided to Medicaid members free of charge by the Vaccines for Children (VFC) program.

    Pharmacies that bill Medicaid for the cost of vaccines that are obtained via the VFC Program are subject to recovery of payment.

    Limited to the 2023-2024 vaccine season, non-VFC enrolled pharmacies, may bill the COVID-19 vaccine per the guidance posted here.

    • Pharmacies wishing to administer VFC-available vaccines to Medicaid members younger than 19 years of age may enroll in the VFC program. 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

Table A

NCPDP D.0. Claim Segment Field Value
436-E1 (Product/Service ID Qualifier) Enter the applicable value of 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 in accordance with ACIP recommendations in accordance with ACIP recommendations and State law:

Table B

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.

Table C

Procedure Code Procedure Description
90460 Immunization administration through 18 years of age via any route of administration $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.

Please note: Vaccine counseling visits for Coronavirus Disease 2019 (COVID-19) vaccinations are reimbursed separately. Providers can refer to the Updated COVID-19 Vaccine Counseling Coverage guidance, located here, for more information.

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: