Date Issued: 3/28/2019
Last Updated: 11/14/2023
EmblemHealth is committed to our partnership with the Vaccines for Children (VFC) Program.
The VFC Program is administered by New York City in conjunction with the New York City Department of Health and Mental Hygiene (NYC VFC), and New York State for non-city residents (NYS VFC).
Collectively, these programs distribute free vaccines to eligible providers serving Child Health Plus (CHPlus) and Medicaid members ages 18 and younger throughout our service area:
- New York City (Bronx, Kings, New York, Queens, and Richmond counties)
- Nassau County
- Suffolk County
- Westchester County
Administering covered vaccines
Below is a list of covered vaccines that may be administered by NYS-certified pharmacists to members as follows.
|Members between the ages of two and 18||Members 18 years of age||Members 19 years of age and older|
Members are eligible to get the flu vaccine at participating pharmacies.
Some pharmacies can also provide other vaccinations recommended for older adults, including:
Pharmacy billing and reimbursements for covered vaccines
As of April 1, 2023, Medicaid Managed Care (MMC) pharmacy benefits that are billed on pharmacy claims were transitioned to NYRx, the New York State pharmacy program. NYRx should never be billed for the cost of any vaccine for Medicaid members 18 years of age and younger when the vaccine is available through the NYS/NYC VFC Programs. Pharmacy claims for the cost of administering vaccines to Medicaid members should be submitted to NYRx for reimbursement.
EmblemHealth should never be billed for the cost of any vaccine for CHPlus members 18 years of age and younger when the vaccine is available through the NYS/NYC VFC Program. EmblemHealth will only reimburse pharmacies for the cost of administering vaccines to CHPlus members.
Below is information regarding the most current list of vaccines covered in each program:
- NYC VFC Vaccines
- The Citywide Immunization Registry (CIR) includes a notation for vaccines covered in the VFC Program (see column to the far right) and CPT codes.
- Vaccines with a “Y” indication in the VFC column will be auto-denied when administered to any VFC-eligible members 18 years of age and younger.
- NYS VFC Vaccines
- For the most up-to-date vaccines covered in the NYS program, refer to the CDC VFC Price List.
- Review both the Pediatric/VFC Vaccine Price List and the Pediatric Influenza Vaccine Price List for the vaccines covered under VFC.
- These vaccines will be auto-denied when administered to any VFC-eligible members 18 years of age and younger. Check the related CPT codes.
Pharmacy billing for covered vaccines for CHPlus members 18 years of age and younger:
- At VFC participating pharmacies:
- Covered CHPlus members ages two and older are eligible for the flu vaccine.
- Covered CHPlus members ages three and older are eligible for the COVID-19 vaccine.
- Covered CHPlus members age 18 only are eligible for other covered vaccines (listed above).
- The adjudication system will identify when a VFC product is being billed for a CHPlus plan member 18 years of age and younger. The pharmacy will be notified that the requested vaccine is eligible and must be billed under VFC.
|If the dispensing pharmacy is enrolled in VFC.||If the dispensing pharmacy is not enrolled in VFC.|
● The pharmacy will get a rejection message from the CHPlus plan.
● The message will instruct the pharmacy to bill VFC for the vaccine and submit the procedure code 90460 for “administration of free vaccine” to get reimbursement from the plan.
● Messaging will include phone numbers to VFC program assistance.
● The pharmacy will get a rejection message from the CHPlus plan that will instruct the pharmacy on the necessary override codes.
● These override codes allow the member to pay zero dollars and the dispensing pharmacy will be reimbursed the appropriate dispensing fee. The cost of the vaccine is not covered by the CHPlus plan.
Pharmacy billing for covered vaccines for CHPlus members 19 years of age and older:
- Claims for covered vaccines listed on our Formulary will process through our regular billing procedure.