Pharmacy-administered adult immunizations (coverage criteria)
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Defines pharmacy benefit coverage and operational expectations for adult immunizations (including influenza) for Medi-Cal beneficiaries aged 19 and older, and instructs providers on eligibility checking and documentation using CAIR per ACIP schedules.
No material clinical or coverage changes in this revision.
Pharmacy Immunization Coverage Criteria
Pharmacy benefit coverage criteria
Covered when ALL of the following are met
Includes consideration of age, prior vaccination status, and medical conditions that increase risk; applies to adults >= 19 years
This pharmacy benefit covers certain adult immunizations provided at pharmacies for members who are not eligible for the Vaccines for Children (VFC) program. The VFC program does not cover Medi-Cal beneficiaries aged 19 years and older, and this pharmacy-administered immunization benefit is expressly intended to expand access for those individuals, including influenza vaccine, when administered per ACIP routine immunization schedules.
Coverage under this pharmacy benefit is restricted to vaccines that are administered in accordance with the current routine immunization schedules published by the Advisory Committee on Immunization Practices (ACIP) of the CDC. Providers must identify eligible members by checking the California Immunization Registry (CAIR) for vaccination status and eligibility considering age, prior vaccination status, and high-risk medical conditions. After vaccine administration, the provider must record the encounter in CAIR to support coverage and billing.
Coding and Age Threshold
| No codes listed |
Provider Responsibilities and Documentation
Prior authorization not required when ACIP + CAIR conditions met
No prior authorization is described for pharmacy-administered adult immunizations when vaccines are given in accordance with current ACIP routine immunization schedules and recorded in the California Immunization Registry (CAIR).
Verify eligibility via CAIR and ACIP schedule
Confirm member eligibility and follow ACIP routine immunization schedules; check CAIR for vaccination history and eligibility before administering vaccines.
- Identify eligible members by checking the CAIR website for vaccination based on current ACIP guidelines.
- Consider age, prior vaccination status, and high-risk medical conditions when determining eligibility.
Record vaccination encounter in CAIR
After administering the vaccine, record the vaccination encounter in the California Immunization Registry (CAIR).
- Use CAIR to document the administered vaccine immediately following vaccination.
Coverage depends on ACIP-compliant administration and CAIR documentation
Coverage is contingent on vaccines being administered per current ACIP routine immunization schedules and the encounter being recorded in CAIR; failure to meet these conditions may affect coverage or billing.
- The pharmacy benefit is restricted to immunizations administered in accordance with current ACIP schedules.
- Failure to record the encounter with CAIR after administration may affect coverage.
Background
Pharmacies are positioned to expand access to adult immunizations for members not eligible for the Vaccines for Children program. The policy emphasizes pharmacy delivery of several adult vaccines, including influenza, for Medi-Cal beneficiaries aged 19 years and older. Eligibility and vaccine administration must follow current ACIP routine immunization schedules, and encounters must be recorded in the California Immunization Registry (CAIR).
Key Definitions
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