What to do if CDC’s ACIP makes a ‘permissive’ recommendation

Does a pharmacist need a prescription to administer the vaccine?

Question: If CDC’s ACIP makes a “permissive” recommendation, does a pharmacist need a prescription to administer the vaccine?

Answer: Many factors determine what a pharmacist is allowed to do, in addition to CDC’s Advisory Committee on Immunization Practices (ACIP) recommendations. A permissive recommendation is an older term that is no longer preferred by ACIP. It was felt to be confusing to providers, did not provide sufficient guidance, and many insurance plans would not pay for a vaccine with a permissive recommendation.
The Affordable Care Act (ACA) of 2010, which was expanded in 2014, required most private health care insurance plans to provide payment for many preventive services with no cost sharing. This included vaccines determined to be for routine use by ACIP. Other insurances include military insurance (TRICARE), Medicaid (fee dependent on state with patient lives), and Medicare, according to an HHS website for vaccines. Medicare Part B only provides payments for influenza, pneumococcal, and hepatitis B (certain conditions) vaccines. All other vaccines are covered under Medicare Part D, with cost sharing determined by the plan the patient has selected. As of this time, there are no “B” recommendations for vaccines recommended for adults aged 65 years and older, according to the CMS website.

GRADE (Grading of Recommendations, Assessment, Development and Evaluation) is a new evidence-based framework for ACIP to use in making recommendations. This method takes into account the balance of benefits and harms, type or quality of evidence, values and preferences of the people affected, and health economic analyses, according to the CDC website. The recommendations are made in one of three categories: A, B, or no recommendation. A Category “A” recommendation means the ACIP recommends the vaccines for all persons in an age group or for persons at-risk for disease.  A category “B” recommendation does not apply to all members of a group, but provides guidance for providers to help the patient or guardian make a decision to vaccinate or not.  (https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6118a3.htm)

ACA requires most plans mentioned above to provide payment coverage for all vaccines recommended by ACIP, both with “A” and “B” recommendations. The remaining factors that determine what a pharmacist can do are dependent upon state laws, rules, and regulations. The age of the patient, the requirement of a prescription or not, the use of standing orders, and the vaccines that can be administered by a pharmacist are state specific.  It is important to note that standing orders may not be all inclusive. Additionally, employers may set corporate policy that may be different from state laws.

While most states do allow pharmacists to administer and bill for vaccines with a “GRADE B” recommendation, one should consult with their state board of pharmacy to be certain. After determining that one’s state allows pharmacists to administer and bill for vaccines, the next step is to check with the insurer regarding payment.