Influenza Vaccines
Traditional Medicaid
During influenza season, pharmacies may bill for influenza vaccines provided to people seven and older in a pharmacy setting for influenza vaccines available on the Medicaid formulary as part of the pharmacy benefit. The pharmacist administering the vaccine does not have to enroll with TMHP but must follow the Texas State Board of Pharmacy's (TSBP) rules related to certification to immunize and vaccinate. Refer to TAC Section 295.15 (Chapter 295: Administration of Immunizations or Vaccinations by a Pharmacist under Written Protocol of Physician).
Administering pharmacists are health care professionals licensed by the TSBP to practice as a pharmacist, have met and maintained the eligibility requirements outlined in law, and have been certified by the TSBP to administer vaccines.
Administering pharmacists are under the supervision of a physician under state law and may administer immunizations or vaccinations only under a physician’s written protocol authorizing the administration. Pharmacists are employed and remunerated by a pharmacy for their services. If the program’s services are covered and reimbursable, payment may be made to the pharmacy employing the licensed pharmacist. HHSC will reimburse pharmacies for the ingredient costs and applicable administration fees.
Refer to the Formulary search (txvendordrug.com/formulary/formulary-search) for a list of products.
Pharmacy providers should submit the values identified below. Refer to the Claims Billing (B1) Transaction for specific transaction, segment, and field requirements.
| Field # | Field Name | Value |
|---|---|---|
| 438-E3 | Incentive Amount Submitted | |
| 439-E4 | Reason for Service Code |
PH = Preventive Health Care PN = Prescriber Consultation RF = Health Provider Referral |
| 440-E5 | Professional Service Code | MA = Medication Administration |
| 441-E6 |
Result of Service Code |
3N = Medication Administration |
Medicaid managed care and CHIP
During influenza season MCOs are required to allow pharmacies to bill for influenza vaccines provided to people aged seven and older in a pharmacy setting. MCOs must cover all influenza vaccines available on the Medicaid and CHIP formularies as part of the pharmacy benefit. MCOs must reimburse pharmacies for the ingredient cost and applicable administration fees for flu vaccines. Pharmacies providers should contact the client's specific MCO for details.