Lincoln Alexander, PharmD

In an effort to avoid further strain on a health care system already responding to the coronavirus disease 2019 (COVID-19) global pandemic, the CDC stressed the increased importance of receiving this year’s seasonal influenza vaccination, which is recommended for everyone 6 months or older.

 The need to reduce this potential concurrent system strain has caused health care professionals, government officials, and research experts to use social media and news outlets to encourage patients to receive vaccines earlier in the season compared with last year. Additionally, in response to an expected increase in demand for the influenza vaccine, manufacturers plan to ramp up production and pharmacies are ready for an unprecedented busy season.

 A thorough understanding of immunization billing processes for Medicare, Medicaid, and other third-party payers will be critical to ensure pharmacy staff can efficiently serve their communities and facilitate a smooth reimbursement process. This review of third-party payer immunization guidelines includes considerations for seasonal immunizations and the COVID-19 vaccine(s) under development.

A large portion of patients receiving influenza and other eligible vaccines in community pharmacies have commercial health insurance with prescription coverage.

For example, approximately 52% of children 5 years or younger are covered by private insurance.

 To successfully bill for immunizations, the pharmacy must be contracted with the patient’s specific plan. If contracted, pharmacies can typically bill for influenza and other vaccines in real time using the patient’s prescription insurance information. In some cases, the medical plan must be billed rather than the drug benefit plan, in which case the pharmacy must be contracted to bill the medical plan instead. For medical billing, an immediate adjudication response is not common, although there are billing systems available that can check eligibility and provide a cost estimate. It is important to notify these patients that they may be responsible for a future co-pay—up to the full cost of the vaccine&mdash;after their medical plan finishes the adjudication process within a couple of weeks, especially if they have not met their plan’s deductible.

Often, a more complicated patient population to successfully bill for regarding influenza vaccines includes those with Medicare coverage, most of whom are 65 years or older. Most Medicare beneficiaries are eligible to receive 1 influenza vaccine each influenza season with direct pharmacy reimbursement by Medicare Part B or through a Medicare Advantage plan (Part C),

 assuming they choose a pharmacy that is contracted with Medicare.

 When billing Medicare Part B, pharmacies will need the patient’s identification number, which can be found on their red, white, and blue card.

 For most pharmacy software systems, Medicare Part B is not billed directly through online adjudication but rather through the mass immunization roster billing process in which a Medicare-enrolled provider, such as a pharmacy chain, works with a Medicare administrative contractor to compile a list of claims to submit through a centralized process on the pharmacy chain’s behalf.

 Medicare Part B covers medical and preventive services including influenza, pneumococcal, and hepatitis B vaccines.

 For these types of vaccines, there is typically zero copay for the patient. Of note, Medicare Part B will also pay for other vaccines as treatment after potential exposure has occurred, such as when a patient steps on a rusty nail and is at risk of contracting tetanus or has been bitten by an animal suspected of spreading rabies.9 For other types of regular preventive vaccines not covered by Part B, Medicare Part D may pay, assuming the patient has this coverage. However, Medicare Part D may require prior authorizations and/or additional copays for the provision of vaccinations.

MEDICAID COVERAGE AND OUT-OF-POCKET PAYMENTS 

Pharmacies should be prepared to offer immunization solutions or referrals for patients covered by local Medicaid plans. Medicaid plans do not have a standardized approach for vaccination administration and billing. Each state and county’s Medicaid plan decides which vaccines will be covered, who can provide those vaccines, and the vaccine and/or administration reimbursement rates.

 Pharmacists can familiarize themselves with the local Medicaid vaccine billing procedures, which are often available online or via a toll-free phone number.

There also will be uninsured patients and others who choose to pay for vaccinations out of pocket. As influenza symptoms may overlap with the symptoms of COVID-19, the cost of an unnecessary 2-week quarantine or the fear of needing care in overloaded health care facilities could correlate to an uptick in a patient’s willingness to pay out of pocket for the vaccine. Pharmacies can offer deals or incentives to help ease the financial burden of patients who need to pay out of pocket to receive an influenza shot. Such options include coupons or gift cards that can be used on store merchandise, as well as discount cards for the shot itself. At most big-box pharmacy chains, contracted discount cards also may give uninsured patients a price break.

One last option for patients is to receive their influenza vaccine for free through a government agency or a nonprofit local health organization.

 For example, the CDC has taken the unusual step of purchasing 7 million doses to be distributed to states for adult vaccination.

 Furthermore, eligible children can receive vaccines at no cost through the Vaccines for Children (VFC) program.

 These free vaccines are subject to state-specific distribution and billing limitations, and many pharmacies choose not to participate because of no or very low administration reimbursement. In states paying the pharmacy an administration fee through the VFC program, these vaccines are most commonly billed through the state’s Medicaid plan.

An understanding of how influenza and other vaccines are billed is important, especially when one confronts the ongoing COVID-19 global pandemic for which the country is expected to have 1 or more vaccines available soon. The Coronavirus Aid, Relief, and Economic Security (CARES) Act requires all health plans to pay the entire cost of the vaccine as a preventive health service, although it may not be covered immediately. The approved vaccine for COVID-19 would have to be recommended by the US Preventive Services Task Force, the CDC, and the Advisory Committee on Immunization Practices. When a vaccine is recommended, the CARES Act will accelerate required coverage from the standard wait of up to 1 year down to 15 days from the date of approval.

 Once the vaccine is covered, pharmacies should be able to bill using the same procedure as for other vaccinations.

The pharmacist remains a critical member of the health care system, providing vaccinations that help promote health, prevent disease, and minimize strain on other segments of the system. All pharmacy staff must be knowledgeable about the billing of various vaccines, as well as the options available to patients when they are paying for vaccines. This influenza season, pharmacists will continue to provide essential services for America’s communities, including an expected record number of influenza vaccines followed by or concurrent with a potential COVID-19 vaccination effort. 

, is the corporate pharmacy trainer and residency program director for Albertsons Companies in Phoenix, Arizona.

, is a residency program director and student experiential coordinator at Albertsons Companies in Portland, Oregon. He is an alumnus of Oregon State University College of Pharmacy in Corvallis.

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Medicare Part D vaccines. Centers for Medicare & Medicaid Services. June 2019. Accessed October 21, 2020. https://www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNProducts/Downloads/Vaccines-PartD-Factsheet-ICN908764.pdf

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How to pay. Vaccines.gov. Updated June 2020. Accessed October 21, 2020. https://www.vaccines.gov/get-vaccinated/pay

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Articles

A thorough understanding of immunization billing processes for Medicare, Medicaid, and other third-party payers will be critical to ensure pharmacy staff can efficiently serve their communities and facilitate a smooth reimbursement process.

Vaccine Billing Coverage Options: Seasonal Influenza and Future COVID-19 Vaccines

Immunization needs for patients aged 19 to 64 years and afflicted with chronic conditions are often overlooked, and necessitate more attention and resources.

 Pharmacies traditionally do not focus on this patient population; instead often choosing to focus primarily on the population 65 years and over. However, engaging with patients in the 19- to 64-year-old group could go a long way in helping to fill the current immunization void in this population. Potentially, it could be the next “big win” for pharmacy immunizations and increase global immunization rates. Two case studies that highlight various methods for identifying patients who may be eligible for immunizations which can be used to improve vaccination rates in this population are presented below.

A Millennial Patient Requests Refills of Regular Medications

A 26-year-old woman arrived at the pharmacy drop-off window and requested refills of fluoxe- tine and beclomethasone dipropionate hydroflu- oroalkane (HFA) from the pharmacy technician. She stated that she would return to the pharmacy in 20 minutes to pick up her prescriptions.

Was this patient eligible for a vaccination? 

The pharmacy intern at this site previously created a list of medications and their corresponding conditions and vaccines (see table).

(This list was meant as a helpful guide for pharmacy staff and should not be used as a comprehensive list of medications or immunizations.) It enabled pharmacy staff to screen medication prescriptions and easily determine which would likely classify a patient as having a chronic condition and an associated potential need for a vaccination. The list included common drugs such as metformin or insulin products for diabetes; aspirin and/or β blockers, nitroglycerin, and angiotensin-converting enzyme inhibitors for heart disease; albuterol and/or other related inhalers for asthma or chronic obstructive pulmonary disease; and others, and their associated chronic condition, as well as a potentially eligible vaccine (eg, metformin: diabetes:pneumococcal vaccine).

After reviewing the list of potentially vaccination eligible medications, the pharmacy technician discovered that beclomethasone dipropionate HFA was among the medications associated with a potential vaccination, in this case, a pneumococcal vaccine, which is recommended for adults aged 19 to 64 years who have chronic conditions, such as chronic obstructive pulmonary disease and asthma, that put them at risk of pneumococcal disease.

 The technician then researched the patient’s vaccination history through the online vaccine registry and printed it out for pharmacist review. In addition, the technician added a “pop-up” note into the computer system during prescription processing that stated, “Patient on beclomethasone dipropionate HFA, recommend pneumococcal vaccine?”

According to the online vaccine registry, the patient had not yet received pneumococcal vaccination. After seeing the computer pop-up note, and reviewing the vaccine registry information on the print-out, the pharmacist updated the computer’s auto-alert with additional discussion points for the patient regarding the vaccine. When the patient returned to the pharmacy to pick up her prescriptions, the pharmacist initiated a discussion with her, during which he confirmed her asthma diagnosis and that she had not received a pneumococcal vaccination. He then suggested a dose of the pneumococcal conjugate vaccine, PPSV23, in accor- dance with CDC guidelines. The patient agreed and administra- tion of the vaccine occurred in the pharmacy.

A 55-year-old Patient Prescribed Lisinopril Is New to the Pharmacy

A 55-year-old man, new to the pharmacy, arrived with a pre- scription for lisinopril. The pharmacy technician advised the patient that it would take 15 minutes to process the prescription. The patient stated he would browse the aisles of the pharmacy while he waited.

While performing drug utilization review, the pharmacist noted that the new patient was not listed in the pharmacy database. Based on the patient’s age, the pharmacist determined that he might be eligible for the zoster vaccine recombinant, adjuvanted (Shingrix, GlaxoSmithKline) vaccination 2-dose series to provide protection against shingles, which is recommended by the CDC for all immunocompetent adults 50 years and older.

 Because the pharmacy is located in a state without a vacci- nation registry, the pharmacist instead added a software note that would pop up as an auto-alert at the “Will Call” terminal, flagging the pharmacy staff member who was processing the prescription payment to call the pharmacist to speak with the patient regarding potential vaccinations.

When the patient returned to the pharmacy counter to pick up his prescription, the pop-up alert prompted the technician to alert the pharmacist to speak with the patient. After discussion and confirmation that the patient had not previously received a shingles vaccine, the pharmacist explained the importance of receiving the vaccine to protect against the shingles virus and rec- ommended that the patient receive the first of 2 doses in the series for Shingrix. The patient agreed and the pharmacist was able to administer the vaccine in the pharmacy. After administering the vaccination, the pharmacist updated the pharmacy database to indicate that the patient received the first dose. The pharmacist then took time to help the patient set a smartphone reminder for the second dose of the vaccine to help ensure patient follow-up.

Through straightforward identification methods and appropriate staff training, vaccination provision rates among patients who are 19-to-64 years old and with chronic disease can improve. By utilizing the list of medications and their corresponding conditions, as well as the online vaccine registry, the pharmacy technician in 

were able to easily identify potential patients for vaccination.

Identification methods, however, are only part of the process toward improving vaccination rates. Effective, motivating communication—from the beginning of a patient encounter to the end&mdash; remains a key reason patients receive recommended vaccination(s). For example, in 

, before discussing immunization with the patient, the pharmacist first confirmed that she was diagnosed with the condition associated with the prescribed medication. To give another example, in the case of a female patient prescribed metformin, the pharmacist would want to con- firm metformin was prescribed for diabetes and not polycystic ovarian syndrome.

Communication extends beyond that which occurs between the pharmacist and the patient; pharmacy staff should be involved, too. Although the pharmacist in 

flagged a potential vaccination through a computer pop-up, these alerts often can be bypassed without being read. Another way of highlighting patients as potentially eligible for vaccination include writing a note —“Vaccine?”&mdash;on the will-call receipt when bagging the item during receipt print-off after final pharmacist verification of the prescription. Pharmacy staff also can create a vaccination reminder tool, such as a large reusable amber vial with color stickers and the word “VACCINE” written in all caps on both sides of the vial. After completing the will-call transaction, the handwritten “Vaccine?” receipt note flags the pharmacy staff member to place the amber vial tool on top of the patient’s pharmacy order and requests the pharmacist for a vaccination consult.

During the vaccination consult between the pharmacist and the patient, emphasis should be placed on the “why” and the “how” of getting the vaccine, the importance of receiving the vaccine while the patient is at the pharmacy, and asking open-ended questions. Empathy, active listening, and proper education are critical components of these conversations, because many patients have valid concerns that need to be addressed, such as concerns about possible adverse effects, insurance copays, etc. Particularly in the case of a patient who is new to the pharmacy, as in 

, the attentiveness to vaccination status and the overall health of the patient, as well as taking the extra time to set up a reminder for the patient on their smartphone, may go a long way to ensure patient satisfaction and make the patient more likely to become a long-term customer. (For additional techniques on engaging patients, see “Complete Immunization Services Start With Gathering Patient Information” on page 22.)

Improving vaccination rates in 19- to 64-year-old patients with chronic medical conditions requires a multifaceted approach that includes understanding clinical recommendations, how to identify patients, and how to effectively communicate and motivate patients. Further pharmacist responsibility includes training pharmacy staff on these processes to secure effective team communication and follow-through. Collaboration and teamwork within the pharmacy are critical to success in the mission to improve vaccination rates in this population.

Alexander L. Immunizing the 19- to 64-year-old population with chronic disease. 

® website. pharmacytimes.com/publications/supple- ments/2019/june2019/immunizing-the-19-to-64yearold-population-with-chron- ic-disease. Published June 30, 2019. Accessed October 16, 2019.

Recommended adult immunization schedule by medical condition and other indications, United States, 2019. CDC website. cdc.gov/vaccines/schedules/hcp/ imz/adult-conditions.html. Reviewed February 5, 2019. Accessed October 17, 2019.

Pneumococcal disease: risk factors and transmission. CDC website. cdc.gov/pneumococcal/about/risk-transmission.html. Reviewed September 6, 2017. Accessed October 17, 2019.

New shingles vaccine fact sheet for healthcare providers. CDC website. cdc.gov/shingles/multimedia/shingles-factsheet-hcp.html. Reviewed July 1, 2019. Accessed October 17, 2019.

Immunization needs for patients aged 19 to 64 years and afflicted with chronic conditions are often overlooked, and necessitate more attention and resources. Pharmacies traditionally do not focus on this patient population; instead often choosing to focus primarily on the population 65 years and over. However, engaging with patients in the 19- to 64-year-old group could go a long way in helping to fill the current immunization void in this population.

Exploring Techniques to Increase Vaccination Rates Among Adult Patients with Chronic Disease

Immunization screening and provisions in the pharmacy setting often focus on initiatives for adults over 65 years of age. Yet the majority of the US population is between the ages of 18 and 64, with many of these individuals suffering from a chronic condition: The CDC estimates that 6 in 10 US adults have a chronic disease, and 4 in 10 have 2 or more.

 The most common chronic conditions, and the biggest drivers in annual health care costs for US adults, include heart disease, cancer, chronic lung disease, diabetes, and chronic kidney disease.

 Chronic health conditions with specific adult vaccination recommendations include those above, as well as HIV, chronic liver disease, iatrogenic immunosuppression, sickle cell anemia, and asplenia.

To better serve adults aged 19 to 64 years with chronic conditions, an easy-to-use vaccine guide, based on the CDC’s recommendations, is included below (see table).

 Additional resources to improve immunization screening practices for this patient population are also provided.

Current guidelines recommend that all adult patients aged 19 to 64 years—except those with allergies to components of the vaccine or contraindications&mdash; get an annual flu vaccine, a tetanus (or tetanus, diphtheria, and pertussis) booster every 10 years (assuming prior vaccination history), and the shingles vaccination series at 50 years or older.

Improving screening procedures for recommended vaccinations can be as simple as providing a vaccine screening questionnaire to patients to better identify chronic health conditions. The CDC offers an excellent questionnaire at 

cdc.gov/vaccines/hcp/adults/downloads/patient-intake-form.pdf

 This form can help explain to patients the importance of preventive health. After the patient fills out the form, the pharmacist can scan it into the computer charting system, analyze it, bill the patient’s insurance, and give recommended immunizations at the required intervals.

Resources for vaccine series follow-up are important yet often not discussed. Pharmacy staff can try to help patients set smartphone reminders at the end of their appointment to inform them when their next vaccine is due. Pharmacy staff can also provide appointment cards to remind patients when their next vaccine(s) are due and use technology means, such as text message reminders, to follow up with patients at appropriate intervals.

Using the aforementioned tools, pharmacists can better serve their adult patients with chronic condition immunization needs. 

, is a residency program director and student experiential coordinator at Albertsons Companies in Portland, Oregon. He is an alumnus of the Oregon State University College of Pharmacy. 

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The most common chronic conditions, and the biggest drivers in annual health care costs for US adults, include heart disease, cancer, chronic lung disease, diabetes, and chronic kidney disease.