Vaccine season. For a pharmacy owner, it’s our Super Bowl. The phones ring off the hook, the line at the counter is long, and the “flu shot” sign in the window is your best marketing tool.
It’s a massive public health victory. But as a business owner, I have to ask the question that kept me up at night: Are you actually making money on all this work?
Patients walk in every day asking, “What’s the flu shot cost with insurance?” or “Can I get my covid vaccine here?” They see ads for a “CVS flu shot” and assume it’s simple.
They have no idea about the billing minefield on our side.
Here’s the hard truth I learned as a pharmacy owner: The single biggest billing mistake a pharmacy can make is billing the patient’s PBM (pharmacy benefit) instead of their medical benefit.
This one mistake is the difference between getting paid $5 for your work and getting paid $40+. You are doing the work—you deserve to get paid for it. This guide will explain exactly how to bill for both the product and your administration service to maximize your reimbursement.
The Billion-Dollar Mistake: PBM vs. Medical Benefit
When you give a vaccine shot, the claim can go down two very different paths. One path leads to frustration, the other leads to profit.
Path 1: The PBM (Pharmacy Benefit)
- How you bill: You run it through your pharmacy software just like a prescription, using an NDC number.
- The Result: The PBM (like Express Scripts or CVS Caremark) sees this as a product. They might pay for the drug, but they will almost always pay $0 or a tiny, bundled fee for your time (the administration). You’re treated like a vending machine.
Path 2: The Medical Benefit (The Profit Path)
- How you bill: You submit the claim to the patient’s medical insurer (like Medicare Part B, Aetna, or BCBS) using a CMS-1500 form.
- The Result: The medical payer sees this as a clinical service. They are set up to pay for both the product and your clinical labor. You are treated like a provider.
The Golden Rule of Vaccine Billing: A profitable vaccine claim always has at least two line items:
- The Product: The CPT code for the vaccine itself.
- The Service: The CPT code for the administration.
If you are only submitting one line item, you are leaving money on the table. Period.
The New Language: Vaccine Billing Codes 101
To bill the medical benefit, you stop using NDCs and start using CPT codes. You need two types.
1. Product Codes (What You Gave)
These codes tell the payer what vaccine you administered.
- Example (Flu): 90686 (Influenza vaccine, quadrivalent, 3 years and older)
- Example (Pneumonia): 90677 (Pneumococcal 20-valent)
- Example (COVID): 91317 (COVID-19 vaccine, 97mcg/1mL, Novavax)
Note: These codes change constantly. You must check the AMA and CDC websites for the correct codes for the current season.
2. Administration Codes (The Work You Did)
These codes tell the payer, “I counseled the patient and safely administered the vaccine.” This is where you make your margin.
- 90471: The “workhorse” code. Use this for the administration of one vaccine to a patient (non-Medicare).
- +90472: The “add-on” code. If you give a flu shot and a Tdap at the same time, you bill 90471 for the first and 90472 for the second.
- G0008: The Medicare code. Use this for administering the flu shot to a Medicare Part B patient.
- G0009: The Medicare code for administering the pneumonia vaccine.
- G0010: The Medicare code for administering the hepatitis B vaccine.
A Payer-by-Payer Cheat Sheet for Max Reimbursement
“Who do I bill?” is the most common question. Here is the simple breakdown.
Medicare Part B
This is your most important payer for vaccines.
- What it Covers: Flu, Pneumonia (Prevnar/Pneumovax), COVID-19, and Hepatitis B (for at-risk patients).
- How to Bill: You MUST bill Medicare Part B directly as the primary medical payer. Do not touch the patient’s PBM card.
- The Workflow:
- Get the patient’s red, white, and blue Medicare card.
- Bill Part B on a CMS-1500 claim (or via your software, if it can handle medical billing).
- Claim Example (Flu Shot):
- Line 1: G0008 (Admin code) – $ [Your Price]
- Line 2: 90686 (Product code) – $ [Your Price]
- Why it’s a “Must-Do”: Medicare Part B reimbursement for the administration fee is typically $30-$40, plus the cost of the vaccine. This is a massive, reliable revenue source.
Medicare Part D
This is the “tricky” one. Part D (the PBM plan) covers vaccines not covered by Part B.
- What it Covers: Shingles (Shingrix), Tdap, and RSV.
- How to Bill: This DOES go through the PBM, but you must ensure your contract allows you to bill for both the product and an administration fee. Many pharmacies use a billing service or “Vaccine-Only” e-prescriber to ensure this is processed correctly.
Private / Commercial Payers (Aetna, BCBS, Cigna)
This is the “Wild West” and where most pharmacies lose the most money.
- What it Covers: All preventative vaccines (flu, Tdap, Shingrix, etc.) are typically covered at $0 cost to the patient under their medical benefit.
- How to Bill: Do NOT run this on their POne-Time-Only card. You must bill their medical plan.
- The Workflow:
- “May I please see your medical insurance card, not your pharmacy one?” This one question will change your business.
- Bill the medical plan using the 90471 (admin) and the correct product code.
- Why? When a patient asks about their tdap cost with insurance, the PBM might show a $30 copay. The medical plan will almost always show a **$0 copay**. You get the patient a better deal and you get paid a $30-$40 admin fee from the insurer. This is a true win-win.
Your 3-Step Action Plan to Fix Your Vaccine Billing
You can start this today.
Step 1. Get Credentialed (The Foundation) You cannot bill Medicare Part B or private medical plans if you are not credentialed with them. This is the non-negotiable first step. It’s a mountain of paperwork, but it unlocks all your future clinical revenue.
(Editor’s Note: This process is so critical, we made it our primary Pillar Page. Read it here: The Pharmacist-Owner’s Guide to Medical Billing & Reimbursement.)
Step 2. Train Your Staff on This One Script Your team is your most valuable asset. Train every technician and pharmacist to ask this one, critical question for every vaccine patient:
“May I please have your red, white, and blue Medicare card?” …or… “May I please have your medical insurance card, not just your pharmacy one?”
This single workflow change is the key to getting the right billing information.
Step 3. Get the Right Billing Partner As a pharmacist-owner, my time was my most valuable asset. I didn’t have time to chase down $30 rejections, learn 50 different payer rules, or manage credentialing.
You can do this yourself, but a specialized medical billing partner (like RxBB) can handle the credentialing, the complex claim submissions, and the denial follow-up for you. We ensure you get paid for every single vaccine shot you give, so you can focus on your patients.
You are doing the work of a frontline provider. It’s time you get paid for it.
