NYS Medicaid Program Pharmacists as Immunizers Fact Sheet
Effective October 14, 2010, the administration of select vaccines by qualified pharmacists employed by, or under contract with, Medicaid enrolled pharmacies is reimbursable under NYS Medicaid. Administration of vaccines is 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.
- This information only applies to Medicaid fee-for-service enrollees. Medicaid Managed Care and Family Health Plus beneficiaries continue to access immunization services through their health plans. Pharmacists should check with the beneficiary's health plan before immunizing to determine the health plan's coverage policy regarding immunizations provided by pharmacists.
- Reimbursement is 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 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. Pharmacies will bill with a quantity of "1" and a day supply of "1".
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 G0008 Administration of seasonal influenza virus vaccine, intramuscular use 90473 Administration of seasonal influenza intranasal vaccine G0009 Administration of pneumococcal vaccine - The Seasonal Flu vaccine for individuals under the age of 19 is being provided free of charge by the Vaccines for Children (VFC) program. Therefore, Medicaid will not reimburse providers for the Seasonal Flu vaccine for individuals under the age of 19. For VFC enrollment information, go to:
http://www.health.ny.gov/prevention/immunization/vaccines_for_children.htm - The following chart describes the codes and fees that are reimbursable to pharmacies.
| Immunization Type | Code For Vaccine | Code for Administration | Medicaid Reimbursement for Vaccine | Medicaid Reimbursement for Administration (Amount varies based on billing provider) | Vaccine for Children Program (VFC) |
|---|---|---|---|---|---|
| Age 19 and older | Up to Age 19 | ||||
| Seasonal Flu | 90656 90658 90660 | G0008 for intramuscular administration 90473 for intranasal or oral administration | Actual Acquisition Cost+ | $13.23 $8.57 | $13.23 Bill vaccine administration code only (do not bill vaccine procedure code) $8.57 Bill vaccine administration code only (do not bill vaccine procedure code) |
| Pneumococcal | 90732 | G0009 for intramuscular administration | Same as above | $13.23 | $13.23 Bill vaccine administration code only (do not bill vaccine procedure code) |
The maximum fees for these drugs are adjusted periodically by the State to reflect the estimated acquisition cost. Insert acquisition cost per dose in amount charged field on claim form.
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://www.health.ny.gov/diseases/communicable/influenza/.
