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 3 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.
  5. How can pharmacists determine which vaccines are due?
    Pharmacies performing and billing recipient assessment for purposes of determining the recipient’s vaccination needs should include a review of recipient’s immunization records in the California Immunization Registry (CAIR), as recommended by the American Pharmacists Association (APhA). CAIR can help pharmacists assess their recipients’ immunization histories, which may otherwise depend on potentially incomplete dispensing system records or recipient-reported histories. For more information about pharmacy participation in CAIR, providers may review the CAIR Pharmacy page. Also, to help implement the APhA’s Pharmacists’ Patient Care Process to Immunization Services, providers can reference the Pharmacy Resources page on the EZIZ website.
  6. Pharmacy-Administered Vaccines in Medi-Cal

    Coverage

  7. What vaccines are covered as a pharmacy benefit in the Medi-Cal fee-for-service program for recipients 19 years of age and older?
    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) if the indicated restrictions are met and the recipient has not already received the vaccine.

    For all vaccines in Table, restrictions include:
    • Limited to Medi-Cal beneficiaries 19 years of age and older

    • Use of vaccine must be based on CDC guidelines

    Vaccine Formulations covered
    Tdap 1-dose vial  1-dose syringe
    Hepatitis A 50 units/ml   1,440 units/ml
    Hepatitis A and B 1-dose vial  1-dose syringe
    Hepatitis B 10 mcg/ml   20 mcg/0.5 ml
    20 mcg/ml   40 mcg/ml
    HPV 1-dose vial  1-dose syringe
    Influenza 0.5 ml vial  0.5 ml syringe
    Multi-dose vial 5 ml

    Live, intranasal 0.2 ml
    MMR 1-dose vial
    Meningococcal group B 50-50 mcg/0.5 ml
    Meningococcal group B 120 mcg/0.5 ml
    Meningococcal oligosaccharide diphtheria conjugate 10-5 mcg/0.5 ml
    Meningococcal polysaccharide diphtheria conjugate 4 mcg/0.5 ml
    Pneumococcal 13-valent conjugate 1-dose syringe
    Pneumococcal 23-valent, unconjugated 1-dose vial  1-dose syringe
    Rabies 1 dose vial
    Td 1-dose vial ml
    Varicella 1-dose vial
    Varicella-Zoster Single dose vial 0.5 ml
    Multi-dose vial 5 ml
    Zoster 1-dose vial

    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.

    Note that vaccines solely for travel purposes are a Medi-Cal benefit if deemed medically necessary.

  8. What vaccines are covered by Medi-Cal Managed Care Plans (MCPs) at MCP-contracted pharmacies?
    MCPs are required to provide pharmacy benefits comparable to the Medi-Cal fee-for-service pharmacy program (see Question #6). DHCS reviews each MCP’s 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.

    To find nearby pharmacies covered by their insurance, beneficiaries should call their MCP's member services line on the back of their health plan identification card. The number is also listed in the Medi-Cal Managed Care Health Plan Directory. The HealthMap Vaccine Finder can also help members find local pharmacies. Members should call the in-network pharmacies to confirm immunization clinic hours and ask if the vaccine they need is available.

  9. 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).

  10. When are newly licensed vaccines required to be covered by Medi-Cal?
    As soon as the FDA licenses a vaccine for children, both fee-for-service and MCPs are required to cover it, regardless of whether the vaccine has been incorporated into the Vaccines for Children (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.
  11. Reimbursement and Participation in the Vaccines for Children (VFC) Program

  12. How much are pharmacies reimbursed for vaccines administered 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 based on the lower of Actual Acquisition Cost (AAC) plus a professional dispensing fee, or usual and customary charges. AAC is determined as the lowest of:
    • National Average Drug Acquisition Cost (NADAC), or Wholesale Acquisition Cost (WAC) + 0% if the NADAC is not available,

    • Federal Upper Limit (FUL), or

    • Maximum Allowable Ingredient Cost (MAIC).

    A professional dispensing fee is also paid for fee-for-service pharmacy reimbursement. The professional dispensing fee methodology is two-tiered, based on total annual (Medi-Cal and non-Medi-Cal) claim volume as follows:
    • $13.20 when less than 90,000 prescriptions are dispensed (requires provider attestation)

    • $10.05 when 90,000 or more prescriptions are dispensed
  13. Can pharmacies receive a fee from Medi-Cal for initiating and administering immunizations for recipients in the Medi-Cal fee-for-service program?
    Yes. Pharmacies are reimbursed for the initiation and administration of vaccinations in accordance with the statutory authority of Welfare and Institutions Code (W&I Code) Section 14132.968 (3), which allows reimbursement of this and other pharmacist services when rendered to Medi-Cal beneficiaries. It also established the rate of reimbursement for pharmacist services at 85 percent of the fee schedule for physician services. The furnishing pharmacists must enroll as an ordering, referring and prescribing (ORP) provider under Medi-Cal prior to rendering this and other pharmacist services. This service must be provided in accordance with the requirements and protocols outlined in the Business and Professions Code (BPC) and California Code of Regulations (CCR) (BPC § 4052.8 and 16 CCR 1746.4). The reimbursement includes the professional services involved in the evaluation and management, in addition to the drug administration fee. Additional information can be found in the Pharmacist Services section of the Pharmacy manual. See also Question #4 regarding reviewing the recipient’s immunization records in CAIR as part of an immunization assessment.
  14. What do pharmacies receive for vaccine administration from a Medi-Cal MCP?
    For recipients 19 years of age and older:

    DHCS capitates payment to the MCPs, which in turn enter into contracts with pharmacies (and other providers). MCPs are required to provide a comparable service to that provided by fee-for-service. This means they must also pay for the initiation and administration of vaccinations when provided by pharmacists in the outpatient pharmacy setting, consistent with the requirements of BPC § 4052.8 and 16 CCR 1746.4. MCPs must pay an administration fee in addition to the cost of the vaccine (see answers to #10 and #11). Note that MCPs may reimburse at rates different than fee-for-service. For details regarding the reimbursement, please contact your contracted MCP.

    For recipients 18 years of age and younger:

    Typically, Medi-Cal beneficiaries 18 years of age and younger receive their immunizations in the office or clinic of their primary care providers; all Medi-Cal pediatric primary care providers are required to participate in the VFC program.

    Pharmacies contracted by MCPs may only be reimbursed for immunizing recipients 18 years of age and younger if the pharmacy is enrolled in the VFC program. MCPs must reimburse for the initiation and administration fees but cannot reimburse for the cost of vaccine (vaccine is provided for free by the VFC program). Additional requirements apply for becoming a VFC provider; however, VFC program enrollment/recruitment of pharmacies is limited at this time.



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