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Pharmacy-Administered Vaccines in California FAQs

Answers to frequently asked questions are provided and grouped into topical categories.

For general questions (not specific to Pharmacy-Administered Vaccines in California) please see the FAQ page.

Pharmacy-Administered Vaccines in General

  1. Are pharmacists authorized to administer immunizations in California?
    Yes. California law authorizes pharmacists to administer immunizations pursuant to a protocol with a prescriber (Business and Professions Code [Bus & Prof Code] section 4052). A pharmacist may also independently initiate and administer vaccines listed on the routine immunization schedules recommended by the Advisory Committee for Immunization Practices (ACIP) for persons three years of age and older if they meet certain requirements (training, basic life support certification, recordkeeping requirements) (Bus & Prof Code section 4052.8 and California Code of Regulations [CCR], Title 16, section 1746.4).

  2. Is a prescription required when a recipient is vaccinated in a pharmacy?
    A prescription from a physician is not required for a pharmacist to administer an immunization regardless of a recipient's type of insurance. However, some pharmacies may have their own policies on prescriptions. If medical providers write a prescription when referring a recipient to a pharmacy for immunizations, it may facilitate administration and the pharmacist reporting the immunization to the primary care provider which is required by regulation (CCR, Title 16, section 1746.4).* *Note: The pharmacy may still bill using the pharmacist's NPI number if the immunizing pharmacist is initiating and administering the vaccine independently, unless a specific arrangement has been made with the prescribing medical provider.
  3. How old must a person be to be immunized by a pharmacist in California?
    By California law, the recipient must be at least three years of age if the pharmacist is independently initiating and administering the vaccine pursuant to Bus & Prof Code section 4052.8, or of any age if the pharmacist is immunizing pursuant to a protocol with a prescriber (Bus & Prof Code section 4025 [a] [11]).
  4. How does the primary care provider find out about his/her recipients' immunizations provided in a pharmacy?
    Pharmacists are required to report any vaccine they administer into the California Immunization Registry (CAIR) and notify the recipient's primary care or prenatal care provider (if known) within 14 days (CCR, Title 16, section 1746.4). Primary care providers can look up their recipient in CAIR to see immunizations administered by pharmacists (and any other health care providers who use CAIR). For more information, visit the CAIR website. Pharmacists who administer vaccines are currently in the process of becoming CAIR users to comply with the new regulation.
  5. Pharmacy-Administered Vaccines in Medi-Cal

    Coverage

  6. What vaccines are covered as a pharmacy benefit in the Medi-Cal fee-for-service program?
    As of February 2016, the following routine adult immunizations are covered as a fee-for-service Pharmacy benefit (see: Contract Drugs List) without a Treatment Authorization Request (TAR) given the indicated restrictions are met and the recipient has not already received the vaccine:

    Vaccine Dose Specification Restrictions
    Diphtheria/pertussis/Tetanus single dose vial 0.5 ml

    prefilled syringe 0.5 ml
    1) Medi-Cal beneficiaries 19 years of age and older. 2) Use of this vaccine must be based on CDC guidelines.
    Hepatitis A 50 units/ml

    1,440 units/ml
    1) Medi-Cal beneficiaries 19 years of age and older. 2) Two doses of vaccine per lifetime. 3) Use of this vaccine must be based on CDC guidelines.
    Hepatitis A and B 1-dose syringe ml

    1-dose  vial ml
    1) Medi-Cal beneficiaries 19 years of age and older. 2) Use of this vaccine must be based on CDC guidelines.
    Hepatitis B 10 mcg/ml
    20 mcg/ml
    40 mcg/ml
    1) Medi-Cal beneficiaries 19 years of age and older. 2) Use of this vaccine must be based on CDC guidelines.
    HPV 1-dose syringe ml
    1-dose vial ml
    1) Medi-Cal beneficiaries 19 years of age and older. 2) Three doses of vaccine per lifetime. 3) Use of this vaccine must be based on CDC guidelines.
    Influenza single dose vial 0.5 ml

    multi-dose vial 5 ml

    prefilled syringe 0.25 ml and 0.5 ml
    1) Medi-Cal beneficiaries 19 years of age and older. 2) Use of this vaccine must be based on CDC guidelines.
    MMR 1-dose vial 1) Medi-Cal beneficiaries 19 years of age and older. 2) Two doses of vaccine per lifetime. 3) Use of this vaccine must be based on CDC guidelines.
    Meningococcal group B single dose syringe 0.5 ml 1) Medi-Cal beneficiaries 19 years of age and older. 2) Two doses of vaccine per lifetime for Bexsero. 3) Use of this vaccine must be based on CDC guidelines.
    Meningococcal group B single dose syringe 0.5 ml 1) Medi-Cal beneficiaries 19 years of age and older. 2) Three doses of vaccine per lifetime for Trumenba. 3) Use of this vaccine must be based on CDC guidelines.
    Meningococcal oligosaccharide diphtheria conjugate single dose vial 0.5 ml 1) Medi-Cal beneficiaries 19 years of age and older. 2) Use of this vaccine must be based on CDC guidelines.
    Meningococcal polysaccharide diphtheria conjugate single dose vial 0.5 ml 1) Medi-Cal beneficiaries 19 years of age and older. 2) Use of this vaccine must be based on CDC guidelines.
    Meningococcal polysaccharide 50 mcg /0.5 ml 1) Medi-Cal beneficiaries 19 years of age and older. 2) Use of this vaccine must be based on CDC guidelines.
    Pneumococcal 13-valent conjugate single dose syringe 0.5 ml 1) Medi-Cal beneficiaries 19 years of age and older. 2) One dose of vaccine per lifetime. 3) Use of this vaccine must be based on CDC guidelines.
    Pneumococcal 23-valent, unconjugated single dose vial 0.5 ml multi dose vial 2.5 ml

    Single dose syringe
    1) Medi-Cal beneficiaries 19 years of age and older. 2) Two doses of vaccine per lifetime. 3) Use of this vaccine must be based on CDC guidelines.
    Rabies 1 dose vial 1) Medi-Cal beneficiaries 19 years of age and older. 2) Use of this vaccine must be based on CDC guidelines.
    Tetanus and diphtheria toxoids adsorbed 1-dose vial ml 1) Medi-Cal beneficiaries 19 years of age and older. 2) Use of this vaccine must be based on CDC guidelines.
    Varicella 1-dose vial 1) Medi-Cal beneficiaries 19 years of age and older. 2) Two doses of vaccine per lifetime. 3) Use of this vaccine must be based on CDC guidelines.
    Zoster 1-dose vial 1) Medi-Cal beneficiaries 60 years of age and older. 2) One dose of vaccine per lifetime. 3) Use of this vaccine must be based on CDC guidelines.

    Additional doses of immunizations other than the above specifications will be covered if the pharmacy secures approval from the Department of Health Care Services (DHCS) after submitting a TAR justifying the medical necessity of the vaccine and the reason it must be given by the pharmacy. The turnaround time for pharmacy TAR approvals is 24 hours.

  7. What vaccines are covered by contracted pharmacies for Medi-Cal managed care health plans (MCPs)?
    MCPs are required to provide pharmacy benefits comparable to the Medi-Cal fee-for-service pharmacy program (see Question #5). DHCS reviews each MCP formulary to ensure comparability on an annual basis.

    See the DHCS All Plan Letter 16-009 (Revised) requiring MCPs to have the ACIP-recommended adult immunizations on the fee-for-service contract drug list as part of their pharmacy formulary benefit (August 2016).

    To find out where to get immunized, recipients should call the MCP's recipient services line to find out which vaccines are covered in pharmacies and which pharmacies are in-network, or view the MCP's formulary and pharmacy list online. Visit the Medi-Cal Managed Care Health Plan Directory for reference. Recipients can then call a local pharmacy and ask if the vaccine they need is available, or use the HealthMap Vaccine Finder to find a local pharmacy that offers the vaccine they need and then call the pharmacy to confirm it has the vaccine in stock.

  8. What vaccines are covered by contracted pharmacies for Medi-Cal managed care health plans (MCPs)?
    Yes. If these requirements are met:

    • The vaccine is considered a fee-for-service pharmacy benefit (see Question #5).
    • The pharmacy accepts Medi-Cal reimbursement for the recipient in fee-for-service; Medi-Cal is accepted by most pharmacies in California.
    • The recipient is 19 years of age or older. (Medi-Cal recipients 18 years of age and younger should get their immunizations from their primary care providers; all Medi-Cal pediatric primary care providers are in the Vaccines for Children (VFC) program.)
  9. Will Medi-Cal cover immunizations administered in a pharmacy to a Medi-Cal managed care recipient?
    Yes. If these requirements are met:

    • The vaccine is considered a pharmacy benefit by the specific health plan (see Question #6).
    • The pharmacy is in the MCP's network. (Contact either MCP recipient services or the pharmacy to find out if immunizations administered at the pharmacy are covered by the MCP.)
    • The recipient is 19 years of age or older. (Medi-Cal recipients 18 years of age and younger should get their immunizations from their primary care providers; all Medi-Cal pediatric primary care providers are in the VFC program.)
    • The vaccine is indicated because of the recipient's age or health condition. Plans may verify the qualifying health condition for which the vaccine is indicated prior to administration or reimbursement of the vaccine.
  10. Must MCPs provide transportation for recipients to pharmacies for immunization?
    Yes. As of July 1, 2017, MCPs must provide transportation for MCP recipients to obtain medically necessary MCP-covered services. This could include transporting a recipient to a pharmacy in their MCP network for immunization. Effective October 1, 2017, MCPs must provide transportation for all Medi-Cal services, including those not covered by the MCP contract.

    See the All Plan Letter 17-010 (Revised).

  11. When are newly licensed vaccines required to be covered by Medi-Cal?
    As soon as a vaccine is licensed by the FDA for children, both fee-for-service and MCPs are required to cover it, regardless of whether the vaccine has been incorporated into the VFC program. As soon as the FDA licenses a new vaccine for adults, both fee-for-service and MCPs must cover it, or a biologically identical vaccine. While the Medi-Cal program covers all ACIP-recommended vaccines, updates to the Medi-Cal provider manual may lag behind, so the Manual may not yet reflect current ACIP recommendations. Activation of the fee-for-service reimbursement mechanism may also lag behind.
  12. Reimbursement

  13. How much are pharmacies reimbursed for administration of vaccines to adults 19 year of age and older in Medi-Cal fee-for-service?
    Pharmacies are reimbursed for vaccines in a similar method as other pharmacy claims. Pharmacies are reimbursed at the lower of:

    • The average wholesale price (AWP)-17 percent,
    • The federal upper limit (FUL),
    • The maximum allowable ingredient cost (MAIC), or
    • The pharmacies usual and customary charge to the general public.

    A $7.25 dispensing fee is also paid for fee-for-service reimbursement.

  14. Can pharmacies receive a vaccine administration fee from Medi-Cal fee-for-service?
    No. Pharmacists do not receive an administration or counseling fee, but they do receive a dispensing fee of $7.25. This is because payment for pharmacist services are not yet authorized in the state Medicaid Plan (the agreement between DHCS and the Centers for Medicare & Medicaid Services [CMS]).
  15. What do pharmacies receive for vaccine administration from a Medi-Cal MCP?
    DHCS capitates payment to the MCPs, which in turn enter into contracts with pharmacies (and other providers). There is no set dispensing fee rate that the MCP must pay. It could be less or more than the $7.25 dispensing fee paid by Medi-Cal fee-for-service. However, MCPs may choose to pay an administration or professional fee in addition to the dispensing fee. MCPs may also reimburse for the cost of vaccine at a different rate than fee-for-service.
  16. Participation in the Vaccines for Children (VFC) Program

  17. Are pharmacies eligible for the California VFC program?
    Yes. Any pharmacy may enroll in the California VFC program as long as they agree to meet federal participation requirements, including:
    • Providing all age-appropriate, routine ACIP-recommended immunizations to children 18 years of age and younger.
    • Vaccinating all VFC-eligible recipients who present to the pharmacy requesting a vaccine as “walk-in” recipients (not just established recipients).
    • Vaccinating VFC-eligible children regardless of their parents' ability to pay the administration fee. This fee must be waived.
    • While a vaccine administration fee, which cannot exceed $26.03, may be charged to non-Medi-Cal recipients (uninsured and American Indian/Alaskan Native recipients), a vaccine administration fee for Medi-Cal recipients cannot be billed to parents of Medi-Cal recipients.

    VFC Program enrollment/recruitment of pharmacies is limited at this time.



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