Pharmacy-Administered Vaccines in California FAQs

Effective January 1, 2022, many pharmacy services, including covered outpatient drugs, enteral nutrition, some medical supplies and the applicable administrative services (for example, claim submission, processing, appeals, authorization, etc.) related to pharmacy claims, transition to Medi-Cal Rx. Pharmacy providers should submit claims for these products to Medi-Cal Rx. For more information on services covered by Medi-Cal Rx, providers should refer to the Medi-Cal Rx website.

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: the Contract Drugs List on the Medi-Cal Rx website) 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 Centers for Disease Control and Prevention (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. When are newly licensed vaccines required to be covered by Medi-Cal?
    As soon as the FDA licenses a vaccine for children, the Medi-Cal program is required to cover it, as a medical and a pharmacy benefit, 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, the Medi-Cal program 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.
  9. Reimbursement and Participation in the Vaccines for Children (VFC) Program

  10. 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. For additional details see the Reimbursement section of the Medi-Cal Pharmacy provider manual.

  11. 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(a)(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.


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