New York State Medicaid Fee-for-Service Program
- Fact Sheet is also available in Portable Document Format (PDF)
Effective October 24, 2024, NYRx will accept vaccine claims billed by National Drug Code. The updated NDC billing process titled, NYRx, Medicaid Pharmacy Program Vaccine Billing Guidance, is found in the Pharmacy Provider Communications. The billing process communicated on this Fact Sheet will remain in effect temporarily until further notice as a billing option during the transition. Note, pharmacies not enrolled in the Vaccines for Children (VFC) program submitting claims for COVID-19 vaccines for patients under the age of 19 must continue to use procedure codes until further notice.
Pharmacists as Immunizers Fact Sheet
(Updated December 31, 2024 - 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 (3 years of age and older)
- Hepatitis A
- Hepatitis B
- Herpes zoster (shingles)
- Human papillomavirus
- Influenza (2 years of age and older)
- Measles, mumps, and rubella
- Meningococcal
- Pneumococcal
- Tetanus, diphtheria, and pertussis
- Varicella
- Other vaccines as recommended by the Commissioner* (see Table B below)
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, and Medicaid policies, including but not limited to 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.
- NYS Medicaid is always the payor of last resort; federal regulations require that all other available resources be used before NYS Medicaid considers payment. Pharmacies must coordinate benefits per the May 2024 Medicaid Update article titled, Pharmacy Reminder: Coordination of Benefits Processing with Other Payer ID and Other Payer ID Qualifier for Pharmacy Claims.
- Dual-eligible enrollees will continue to access immunization services through Medicare.
- Vaccines administered to NYRx and Medicaid Managed Care members residing in a residential health care facility also known as a Long-Term Care Facility (LTC) or an Assisted Living Program (ALP) are the responsibility of the facility. Pharmacies may identify members who reside in either an enrolled residential healthcare facility when the Restriction/Exception code (R/E) indicates “NH”, "N1", "N2", "N3", "N4", "N5", or "N6" on the eligibility response, or in an ALP when the R/E code indicates “AL” on the eligibility response.
- Eligible Medicaid Managed Care (MMC) enrollees will 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 from a physician or a nurse practitioner. These orders must be kept on file at the pharmacy. For either a patient or non-patient specific order, the ordering prescriber's National Provider Identification (NPI) is required on the claim for the claim to be paid. Please see the NYS Medicaid Pharmacy Manual Policy Guidelines section titled, Non-Patient Specific Drug Orders for guidance related to processing these orders.
- Note: Through December 31, 2029, COVID-19 vaccines may be ordered by a pharmacist in accordance with the PREP Act
- 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.
Until further notice or December 31, 2029, non-VFC enrolled pharmacies may continue to bill the COVID-19 vaccinewith the actual acquisition cost of the vaccine.
There are claims processing limitations in billing the COVID-19 vaccine for VFC eligible members by either a non-VFC or VFC enrolled pharmacy.- Non-VFC pharmacies must bill COVID-19 by procedure code.
- VFC enrolled pharmacies must bill COVID-19 at $0.01 ingredient cost.
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 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 to NYRx with Procedure Codes:
- Procedure code billing is required for correct reimbursement for non-VFC providers administering COVID-19 vaccines for patient under the age of 19
- NDC billing is preferred for all other vaccines, see guidance: Correction: NYRx, Medicaid Pharmacy Program Vaccine Billing Guidance
- Procedure code billing for all other vaccines is optional until further notice
Consistent with Medicaid immunization policy, pharmacies will bill the administration fee and, when applicable, acquisition cost of the vaccine using the appropriate procedure codes.
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" into the National Council for Prescription Drug Programs (NCPDP) Field 442-E7 (Quantity Dispensed) and a day supply of "1" in field 405-D5 (Day Supply).
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 a quantity of "1" or "2" in the Field 442-E7 (Quantity Dispensed).
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 the appropriate vaccine procedure code(s) with a cost of $0.00, then submit procedure code "90460" (administration of free vaccine) for administration of first or subsequent doses. 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 administration of two vaccines on the same date to members younger than 19 years of age, procedure code "90460" should be used with a quantity of "2" in Field 442-E7 (Quantity Dispensed).
For NCPDP claims transactions that are rejected for edit 02291, the corresponding Medicaid Eligibility Verification System (MEVS) Reject Reason code "738" will be returned "History Not Found for Administrative Vaccine Claim" and NCPDP Reject code "85" "Claim Not Processed."
Until further notice, VFC enrolled pharmacies will continue to bill $0.01 instead of zero in field 409-D9 (Ingredient Cost Submitted) for COVID-19 vaccines administered to VFC eligible Medicaid members.
The following procedure codes should be billed in accordance with ACIP recommendations and federal or State law:
Table B
| Procedure Code | Procedure Description |
|---|---|
| 90611* | Smallpox and mpox vaccine, attenuated vaccinia virus, live, non-replicating, for subcutaneous use |
| 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 |
| 90623 | Meningococcal pentavalent vaccine, conjugated Men A, C, W, Y- tetanus toxoid carrier, and Men B-FHbp, for intramuscular use |
| 90632 | Hepatitis A vaccine, adult dosage, for intramuscular use |
| 90633 | Hepatitis A vaccine, pediatric/adolescent dosage, two 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 two or three dose schedule, for intramuscular use |
| 90653 | Influenza vaccine, inactivated (IIV), subunit, adjuvanted, for intramuscular use |
| 90656 | Influenza virus vaccine, trivalent (IIV3), split virus, preservative free, 0.5 mL dosage, for intramuscular use |
| 90657 | Influenza virus vaccine, trivalent (IIV3), split virus, 0.25 mL dosage, for intramuscular use |
| 90658 | Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for intramuscular use |
| 90660 | Influenza virus vaccine, trivalent, live (LAIV3), for intranasal use, for use in individuals 2 years through 49 years of age |
| 90661 | Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, 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 (PCV13), 13-valent, for intramuscular use |
| 90671 | Pneumococcal conjugate vaccine (PCV15), 15-valent, for intramuscular use |
| 90673 | Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, 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 |
| 90683* | Respiratory syncytial virus vaccine, mRNA lipid nanoparticles, for intramuscular use |
| 90684 | Pneumococcal conjugate vaccine, 21 valent (PCV21), 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, two dose schedule, for intramuscular use |
| 90740 | Hepatitis B vaccine, dialysis, or immunosuppressed patient, three dose schedule, for intramuscular use |
| 90744 | Hepatitis B vaccine, pediatric/adolescent dosage, three dose schedule, for intramuscular use |
| 90746 | Hepatitis B vaccine, adult dosage, three dose schedule, for intramuscular use |
| 90747 | Hepatitis B vaccine, dialysis, or immunosuppressed patient, four 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 |
| 90759 | Hepatitis B vaccine, for use in individuals 18 years of age and older, three dose schedule, for intramuscular use |
| 91304 | Novavax SARS-COV-2 (COVID-19) vaccine, subunit, recombinant spike protein-nanoparticle+Matrix-M1 Adjuvant, preservative free, 5 mcg/0.5 mL dose, for IM use |
| 91318 | Pfizer-BioNTech SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, tris-sucrose, 3 mcg/0.3 mL dose, for IM use |
| 91319 | Pfizer-BioNTech SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, tris-sucrose, 10 mcg/0.3 mL dose, for IM use |
| 91320 | Pfizer-BioNTech SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, tris-sucrose, 30 mcg/0.3 mL dose, for IM use |
| 91321 | Moderna SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 25 mcg/0.25 mL dose, for IM use |
| 91322 | Moderna SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 50 mcg/0.5 mL dose, for IM 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 | Administration Fee |
|---|---|---|
| 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 |
| 90480 | Immunization administration by intramuscular (IM) injection of SARS-CoV-2 (COVID-19) vaccine, single dose | $13.36 |
Billing Instructions for MMC:
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 New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center.
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.
- NYS Education Department Office of the Professions Frequently Asked Questions (FAQ) webpage for Administration of Immunizations.
- NYS DOH Press Releases webpage for vaccine-related announcements.
