Administrative Policy effective January 1, 2020

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Medicaid Managed Care: NYS Vaccines for Children Program Pharmacy Billing Instructions

The New York State Vaccines for Children (NYS VFC) Program is a federally-funded program that provides vaccines to eligible children at no cost.

Which vaccines are covered under the NYS VFC program when billed by a pharmacy?

Univera Healthcare vaccines include:

  • pneumococcal
  • meningococcal
  • tetanus
  • diphtheria
  • pertussis
  • influenza
  • herpes zoster

Where can Medicaid Managed Care members aged 18 and under receive VFC vaccines?

Vaccines can be received at any in-network VFC pharmacy

How do pharmacies bill VFC vaccines for members aged 18 and under?

  • Bill only the administration fee to Univera Healthcare
  • Verify that the Vaccines are covered by the VFC program
  • Please see the Pharmacy Billing Instructions below. NCPDP field 409-D9 should be submitted with $0.01 acquisition cost.

Where can Medicaid Managed Care members aged 19 and over receive VFC vaccines?

Vaccines can be received at any in-network pharmacy

How do pharmacies bill VFC vaccines for members aged 19 and over?

Please see the Pharmacy Billing Instructions below. NCPDP field 409-D9 should be submitted with the acquisition cost.

Pharmacy Billing Instructions:

Notify Univera Healthcare of your VFC enrollment status so you can be added to our list of covered pharmacies for members between the age of two and 18 years old.

Call 1-800-650-4359, select #3 and then speak or enter the member ID number. Until Univera Healthcare adds your pharmacy to the VFC pharmacy listing, you will need to obtain a temporary override per member to obtain reimbursement for the administration.

After notifying Univera Healthcare about your VFC enrollment status and having successfully obtained a temporary override, VFC pharmacy should submit through an NCPDP D.0 claim with $0.01 for acquisition cost in NCPDP field 409-D9 (Ingredient Cost Submitted), as well as any applicable dispensing fee and administration fees. Other than this modification, nothing else will change for the submission of the claim.

If a VFC flu vaccination claim is submitted with $0.00 for acquisition cost, a reject will be returned; the claim should then be resubmitted with $0.01 for acquisition cost. NYS Medicaid Managed Care plans including Univera Healthcare plan 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. Pharmacies that bill the plan for the cost of vaccines available through VFC are subject to recovery of payment.

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