HHSC currently reimburses pharmacies for influenza vaccines administered to clients seven years and older in a pharmacy setting. Under the federal Public Readiness and Emergency Preparedness Act (PREP Act), pharmacists may order and administer influenza vaccines to clients three years of age and older.
Under managed care, HHSC requires MCOs to reimburse pharmacies for influenza vaccines available on the Medicaid and CHIP formularies administered to members aged three and older in a pharmacy setting by Dec. 17, 2021.
Traditional fee-for-service Medicaid will begin covering influenza vaccines for clients three years and older beginning Nov. 22, 2021.
Pharmacies must adhere to the following:
- Per National Council for Prescription Drug Programs (NCPDP) guidance, pharmacies must submit the National Provider Identifier (NPI) of the pharmacist administering the vaccine or supervising pharmacist in the "Prescriber ID" field (411-DB).
- Pharmacies must submit the NPI of the supervising pharmacist if the pharmacy staff administering the vaccine does not have an NPI (e.g., interns).
- For fee-for-service Medicaid, pharmacies must submit claims with the value of "05" in the "Prescription Origin Code" field (419-DJ). MCOs may choose to use this method or find another way to bypass Medicaid enrollment validation edits. (Note: The billing pharmacy submitting the claim must enroll in Texas Medicaid.) Switch vendors may have their own age limitations in place.
HHSC encourages pharmacies to report to ImmTrac2 and proactively collaborate with primary care medical homes.