EmblemHealth requires all eligible Child Health Plus (CHPlus) and Medicaid providers to participate in the Vaccines for Children (VFC) Program. The VFC Program is a New York State Department of Health (NYSDOH) and New York City Department of Health and Mental Hygiene (NYCDOHMH) program that distributes free vaccines to eligible providers that serve CHPlus/Medicaid members under 19 years of age within New York City (Bronx, Kings, New York, Queens and Richmond counties) and Nassau, Suffolk and Westchester counties. Members that meet these criteria are commonly referred to as VFC-eligible members.
Although vaccinations are a covered benefit for CHPlus/Medicaid members, EmblemHealth is not responsible for the cost of the vaccines available through the VFC Program.
EmblemHealth will only reimburse providers for the cost of administering vaccines to VFC-eligible members. Providers are required to bill vaccine administration code 90460 for administration of vaccines supplied by VFC, including influenza and pneumococcal administration. For reimbursement purposes, the administration of the components of a combination vaccine continues to be considered as one vaccine administration. More than one vaccine administration is reimbursable under vaccine administration code 90460 on a single date of service.
The following is a list of the CPT codes for vaccines that will be auto-denied when administered to any VFC-eligible members under age 19:
| CPT Code | Description |
|---|---|
| 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 |
| 90647 | Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3-dose schedule), for intramuscular use |
| 90648 | Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4-dose schedule), for intramuscular use |
| 90649 | Human papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3-dose schedule, for intramuscular use |
| 90650 | Human papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3-dose schedule, for intramuscular use |
| 90670 | Pneumococcal conjugate vaccine, 13 valent, for intramuscular use |
| 90680 | Rotavirus vaccine, pentavalent, 3-dose schedule, live, for oral use |
| 90681 | Rotavirus vaccine, human, attenuated, 2-dose schedule, live, for oral use |
| 90685 | Influenza, inactivated virus vaccine, seasonal, quadrivalent, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use |
| 90686 | Influenza, inactivated virus vaccine, seasonal, quadrivalent, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use |
| 90696 | Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated (DTaP-IPV), when administered to children 4 through 6 years of age, for intramuscular use |
| 90698 | Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP-Hib-IPV), for intramuscular use |
| 90700 | Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use |
| 90707 | Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use |
| 90710 | Measles, mumps, rubella and varicella vaccine (MMRV), live, for subcutaneous use |
| 90713 | Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use |
| 90714 | Decavac, tetanus and diphtheria toxiods absorbed for adult use |
| 90715 | Tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use |
| 90716 | Varicella virus vaccine, live, for subcutaneous use |
| 90718 | Tetanus and diphtheria toxoids (Td) adsorbed for use in individuals 7 years or older, for intramuscular use |
| 90723 | Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B and poliovirus vaccine, inactivated (DTaP-HepB-IPV), for intramuscular use |
| 90732 | Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use |
| 90734 | Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use |
| 90744 | Hepatitis B vaccine, pediatric/adolescent dosage (3-dose schedule), for intramuscular use |
| 90748 | Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use |
Please see the Pharmacy Services chapter of the Provider Manual for more information on the VFC Program.