We promote consumer access and coverag for pharmacists

We promote consumer access and coverag for pharmacists' quality patient care services. Pharmacists: Partners in Improving Adult Immunization Rates

Immunization Neighborhood Collaboration, coordination, and communication among immunization stakeholders dedicated to meeting the immunization needs of the patient and protecting the community from vaccine-preventable diseases. Coined by APh. A in 2012 • • • Patient and community centric An entire community can invest in assessing, administering, and/or referring patients to receive appropriate vaccines. Supports the sharing and exchanging of immunization data

Vision for Immunizing Pharmacists are an accessible, valued and recognized member of the immunization neighborhood who is authorized and compensated for providing immunization services related to ACIP recommended vaccinations that improve public health. CONFIDENTIAL - NOT TO BE RELEASED WITHOUT APh. A APPROVAL

Recognized Partner "Each member of the immunization neighborhood has an important role to play. We appreciate APh. A's leadership and collaboration by pharmacists in addressing the immunization needs of our diverse communities. All our immunization stakeholders must work together to ensure all our adult patient My colleagues and I at the CDC applaud your accomplishments over are protected from vaccine-preventable diseases. We are making progress and he past twenty years and your continued efforts to improve the still have a long way to go. Thank you for your partnership. “ health of our communities by reducing the risk of vaccine-preventable - LJ Tan, Ph. D diseases. Thank you for the care you provide to your communities, Chief Strategy Officer, IAC he enthusiasm and innovation you have shown in addressing the Co-chair, National Adult & Influenza Immunization needs for expanded access to vaccines, and for your leadership within Summit he Immunization Neighborhood. September 2016 - Anne Schuchat, MD RADM, US Public Health Service Assistant Surgeon General "It takes a village to make an impact, and pharmacists are integral members of CDC the immunization neighborhood focused on improving vaccination rates acros September 2015 the lifespan. Pharmacists and APh. A have demonstrated their commitment to public health through the. Ir action. " - Bruce G Gellin, MD, MPH Deputy Assistant Secretary for Health Director, National Vaccine Office September 2016

US Adult Immunization Plan: • Goal 2: Improve Access to Adult Vaccines • Objective 2. 3 Expand the adult immunization provider network • (NAIP 2. 3. 1) Encourage in-network coverage of adult vaccinations administered in accessible health care delivery settings (e. g. public health clinics, pharmacies) • (NAIP 2. 3. 2) Identify and promote effective collaborative models, best practices (e. g. among physicians and other immunizers) • (NAIP 2. 3. 3) Collect more data to evaluate reported in-network adequacy concerns • (NAIP 2. 3. 4) Strengthen the capacity of public health departments and federally qualified health centers to provide all adult vaccines by sharing effective practices for billing private insurance issuers for vaccination services provided to plan enrollees. • (NAIP 2. 3. 5) Continue to identify the barriers that prevent or discourage pharmacist and other providers in complementary settings from accessing and entering vaccinations into state IIS and reporting vaccinations to the patients’ primary care providers. • (NAIP 2. 3. 6) Clearly articulate the legal, practical, and policy barriers that remain so that the challenges are well understood by partners (e. g. , legislators, lawyers) necessary to advance solutions. • (NAIP 2. 3. 7) Assess the impact of providing vaccination services in accessible and complementary settings (e. g. , pharmacies and community health centers) on vaccination coverage, cost-effectiveness, and care. • (NAIP 2. 3. 8) Increase the number of community health centers that routinely administer vaccinations to adults and report vaccinations to immunization information systems and primary care providers • (NAIP 2. 3. 9) Encourage on-site, occupational health vaccination clinics and involvement of employers to increase employee vaccination rates.

Medically underserved areas served by pharmacies (MUAs) – supports Provider Status case • Geographic positioning and hours of operation of community pharmacies. • One example from a nationwide community pharmacy corporation • over 1/3 rd of their influenza vaccines administered were in pharmacies in MUAs; • in states with the largest MUAs, they provided up to 77. 1% of their influenza vaccines in these areas. • of all influenza vaccinations they delivered, 31% were during off-peak times (59% on weekends and 31% in the evenings), • approximately 31 % of patients during off-peak times were age 65 or older, and 36% had underlying medical conditions. • efforts to provide immunizations beyond those for influenza were complicated by lack of insurance coverage or recognition as in network providers. Increasing Access Points

Access Barrier – Vaccine Abandonment • Study Highlights Coverage Policy Impact on Zoster Vaccine Abandonment • Impact of patient out of pocket expense (co-pays) on patient abandonment of receiving zoster vaccination. • Overall abandonment rate was 38. 9%. • Patient out-of-pocket cost (OOP) remained the most significant predictor of abandonment, • Patients with OOP in the $15 -$34 range (1. 6 time higher) compared with those with OOP ≤$14. 99, and at 5. 53 times higher for those with OOP in the $105 -$174. 99 range. • The study supports the value of recognizing pharmacists as in-network providers and modifying coverage policy regarding patient out of pocket expense. • To access the study go to: http: //www. ajpb. com/journals/ajpb/2016/ajpb_julyaugust 2016/factorsassociated-with-zostavax-abandonment? p=1 American Journal of Pharmacy Benefits, August 2016 (2016; 8(4): -e 0)

Snapshot of progress over the past twenty years… All 50 states, DC, and PR authorize pharmacists to administer vaccines at some level (in 1996, 14 states authorized pharmacists for influenza vaccination) Number of adults getting influenza vaccination in community pharmacy increased from 6% of adults (2004 -2005) to about 25% (2015 -2016) Pharmacists are trained about vaccines across the lifespan and are helping patients complete vaccine series Pharmacies target immunization messages to patients by screening pharmacy records and patients’ medication use to identify need for specific vaccinations. More than 300, 000 pharmacists trained to administer vaccines (up from 40, 000 in 2007) APh. A coined the concept of the “immunization neighborhood” — collaborating, coordinating, and communicating with other immunization stakeholders Pharmacists increase access to vaccines across the lifespan and are helping patients complete vaccine series Pharmacists are an accessible and valued partner on the patient’s health care team APh. A House of Delegates passes policy (2007, 2011) for all pharmacists being up to date on their own vaccinations (rates have approached 90%) All ACPE-accredited schools of pharmacy required to include immunization training in their curricula (2016)

Number of States Authorizing Pharmacists to Administer Influenza Vaccine & Number of Pharmacists Trained to Administer Vaccines Note: NABP states there are 300, 000 39 200000 30 9 40, 000 50000 60, 000 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2004 2002 1996 1987 8 1982 0 100000 120, 000 100, 000 14 10 150000 150, 000 20 6 1979 Number of States Authorized 52 52 49 46 250000 30 before Year 40 41978 & Updated December 2016 States and Territories Number trained 52 50 350000 > 300, 000 300000 0 Number Trained 60

Legal Authority • State law governs health care practice • State-specific regulation • Written or verbal prescriptions • Protocols (similar to nurses and physician assistants) • Statute, Health department or individual physician • Authority varies in regards to • Antigens • Patient Age • Process • In emergency/pandemic Governor may sign a declaration that may expand authority

Pharmacist Administered Vaccines Types of Vaccines Authorized to Administer Based upon APh. A / NASPA Survey of State IZ Laws/ Rules Number of states / territories Any vaccine AL, AK, AZ*, AR, CA, CO, CT, DC*, DE*, FL, GA*, HI, ID, IL, IN*, IA, KS, KY, LA*, MA, ME, MD, MI, MO*, MN, MS, MT, NE, NV, NJ, NM, NC, ND, OH, OK, OR, PA, PR*, RI, SC, SD, TN, TX, UT, VA*, WA, WI Influenza, Pneumo and Zoster (I, P, Z) NH Other combos NY, WV**, WY** 48 50 40 30 20 3 1 10 Other combos I, P, Z Any vaccine 0 Number of states / territories Updated July 2016 * Via Rx for some; ** broad list of vaccines 11

Pharmacist Administered Vaccines Prescriber issued protocols vs Rx Based upon APh. A / NASPA Survey of State IZ Laws/ Rules Number of states / territories 30 30 25 20 15 10 5 0 17 e r N on Pr o/ Rx o r R x Pr ot oc ol oc FL, KS, MN, NV, WI Protocol or Rx (depending on age and/or vaccine) AL, AR, CO, CT, DC, DE, GA, HI, IL, IN, IA, KY, MA, MI, MS, MO, NE, NY, NC, ND, OH, OK, PA, PR, RI, TN, TX, UT, VT, WA Protocol/Rx or No Prescriber/Rx Needed (depending on age and/or vaccine) AK, AZ, CA, ID, LA, ME, MD, MT NH, NJ, NM, OR, SC, SD, VA, WV, WY Number of states / territories 5 Pr ot Protocol Updated July 2016 12

Did You Know… • Some private insurance plans, Medicaid and Medicare cover adult vaccinations administered by pharmacists • 93% of Georgians live within 5 miles of a community pharmacy • Six Georgia counties don’t have a family physician according to the GA Board for Physician Workforce • According to the CDC, the four diseases pharmacists can now provide immunizations cost Georgians more than half a billion dollars in 2010 in lost income and revenue Source: Georgia Pharmacy Association

Georgia Pharmacist Immunization Authority • 2009: Pharmacists authorized to administer influenza vaccines without a prescription. All other vaccines require a prescription • HB 504: Effective July 1, 2015 Allowed pharmacists to administer (in addition to influenza) vaccines for the following vaccine preventable disease without a prescription • Meningococcal • Pneumococcal • Herpes Zoster • Requirements: Pharmacists must be in a protocol agreement with the physician • Patients 18 years or older only for Men, Pneum, Zoster (>13 yo for influenza)

Additional Georgia Requirements • Enter vaccine information into Georgia Registry of Immunization Transactions and Services (GRITS) (required of all providers) • Notify primary care physician within 72 hours • Document attempts to identify and notify primary care physician • Take history and determine if patient has seen primary care physician in past year • Privacy: room or privacy barrier • Observe patient at least 15 minutes post vaccination (what do other providers have to do? ) • Adverse event procedures

Increase public understanding Communication / Documentation engagement of providers and patients • Update • Report • Carry • Share GEORGIA: * Provide the patient written information, developed by DPH on importance of having a primary care physician * Provide the patient a vaccine administration record card indicating date of vaccine administration, dosage, and pharmacist’s contact info

Other Georgia Tidbits • Vaccine Protocol Agreement • With a physician registered with DPH vaccination registry in county or contiguous county (is limited exemption to corp in public health district) • Document prescribing vaccines and epinephrine, if determined appropriate by physician for administration by a pharmacist • Protocol must be submitted to the composite medical board and posted in a conspicuous location and include a list of the vaccines authorized by protocol

How Does Georgia Compare?

Pharmacist Administered Vaccines Influenza - Age of Administration Authorized by Any Provision Based upon APh. A / NASPA Survey of State IZ Laws/ Rules Number of states / territories >18 yo >14 yo >12 yo >10 yo >9 yo >7 yo >6 yo >5 yo >3 yo Any age 1 1 0 7 2 3 4 5 5 10 15 20 25 >18 yo CT, FL, MA, NY, PR, VT, WV >14 yo HI*, NC >12 yo MT >10 yo IL >9 yo MD, PA, RI >7 yo AR, ME, OH, WY >6 yo ID, KS, MN, NJ*, WI >5 yo ND >3 yo AZ AL, AK, CA, CO, DED, DC*, GA*, IN*, IA*, KY*, LA*, MI, MS, MO*, NE, NH, NM, NV, OK, OR*, SC*, SD, TN, TX*, UT, VA*, WA 27 30 Any age D Any Updated July 2016 * Requires Prescription age with an adult dose 19

Pharmacist Administered Vaccines Influenza - Age of Adm Authorized by Protocol Based upon APh. A / NASPA Survey of State IZ Laws/ Rules Number of states / territories >18 yo 8 >14 yo 1 >13 yo 1 >12 yo 2 >18 yo CT, FL, HI, MA, NJ, NY, PR, VT >14 yo NC >13 yo GA >12 yo DC, MO >11 yo IN >11 yo 1 >10 yo IL >10 yo 1 >9 yo KY, PA, RI >9 yo 3 >7 yo AR, OH, TX >7 yo 3 >6 yo AZ, IA, KS, MN, WI >5 yo ND AL, CA, CO, DED, MI, MS, NE, NV, OK, SD, TN, UT, WA >6 yo 5 >5 yo 1 Any age 13 0 2 4 6 8 10 12 Any age 14 D Any age with an adult dose Updated July 2016 20

Pharmacist Administered Vaccines Authority to Administer Pneumococcal Vaccine Based upon APh. A / NASPA Survey of State IZ Laws/ Rules States Number of states / territories 60 52 Part B Vaccine 50 40 Number of states / territories 30 20 10 0 0 Yes No AL, AK, AZ, AR, CA, CO, CT, DC*, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MD, ME, MI, MN, MO, MS, MT**, NE, NH, NV , NJ, NM, NC, ND, NY, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VA, WV, WI, WY*** *Via Rx / pt specific protocol for some **Pneumococcal polysaccharide without an Rx; all other forms under protocol ***Pneumococcal polysaccharide only Updated July 2016 21

Pharmacist Administered Vaccines Authority to Administer Zoster Vaccine Based upon APh. A / NASPA Survey of State IZ Laws/ Rules Number of states / territories 60 States 52 50 40 Number of states / territories 30 20 10 0 AL, AK, AZ, AR, CA, CO, CT, DC, DE, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, MD, ME, MI, MN, MO, MS, MT, NE, NH, NY, NV, NJ, NM, NC, ND, OH, OK, OR, PA, PR*, RI, SC, SD, TN, TX, UT, VA, WI, WV, WY 0 Yes No *Via Rx only Updated July 2016 22

Pharmacist Administered Vaccines Authority to Administer Meningococcal Based upon APh. A / NASPA Survey of State IZ Laws/ Rules Number of states / territories 60 Yes AL, AK, AZA, AR, CA, CO, CTA, DCA, DE, FLA, GAR, HIA, IDA, ILA, IAA, IN, KSA, KYA, LAA, MEA, MAA, MDA, MI, MNA, MOA, MS, MTA, NCA, ND, NE, NJA, NM, NYA, NV, OHA, OK, OR, PAA, PRR, A, RIA, SCA, SD, TN, TXA, UT, VTA, VAA, WV, WI, WYA No NH 51 50 40 Number of states / territories 30 20 10 1 0 Yes No Via Rx only Age limitations (may not allow or may require Rx for 11 -18) R A Updated July 2016 23

Pharmacist Administered Vaccines Patient-Age Limitations – for Meningococcal Based upon APh. A / NASPA Survey of State IZ Laws/ Rules Number of states / territories >18 yo >17 yo >14 yo >13 yo >12 yo >11 yo >7 yo >6 yo >3 yo No age limit 21 1 3 3 2 2 1 0 5 10 14 15 20 25 >18 yo CT, FL, GA*, HI*, IA*, KS, ME, MD*, MA, MT, NJ, NY, NC, PA, RI, PRR, SC* VT, VA*, WY >17 yo LA* >14 yo IL, KY*, TX* >13 yo AZ*, MN, OH* >12 yo DC, MO* >11 yo IN*, ND >7 yo AR, OR* >6 yo ID, WI >3 yo CA AL, AK, CO, DED, MI, MS, NE, NV, NM, OK, SD, TN, UT, WA No Age Limit Updated July 2016 *May allow for younger ages under prescription R Via Rx only D Any age with an adult dose 24

Pharmacist Administered Vaccines Authority to Administer Td / Tdap Based upon APh. A / NASPA Survey of State IZ Laws/ Rules Number of states / territories 60 Yes AL, AK, AZ, AR, CA, CO, CT, DC, DE, FL, GA*, HI, IA, ID, IL, IN, KS, KY, LA, MD, ME, MI, MN, MO, MS, MT, NE, NV, NJ, NM, NY NC, ND, OH, OK, OR, PA, PR*, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY No NH 51 50 40 Number of states / territories 30 20 10 1 0 Yes No Updated July 2016 *Via Rx only Many have age restrictions 25

Pharmacist Administered Vaccines Authority to Administer HPV Vaccine WA MT ND OR ID WI AZ CO IN OK OH AL RI CT NJ DE DC NC TN MS MA VA KY AR NH MD WV MO KS TX AK MI PA IL NM NY IA NE NV CA VT SD WY UT ME MN SC GA LA FL HI Pharmacists can administer HPV PR Pharmacists can administer HPV – but only by Rx Pharmacists cannot administer HPV Updated July 2016 26

Pharmacist Administered Vaccines Patient-Age Limitations – for HPV Vaccination Based upon APh. A / NASPA Survey of State IZ Laws/ Rules Number of states / territories >18 yo >17 yo >14 yo >13 yo >12 yo >11 yo >7 yo >6 yo >3 yo No age limit 19 1 3 3 1 2 1 17 0 2 4 6 8 10 12 14 16 18 20 >18 yo AR*, CT, FL, HI*, IA*, KS, ME, MD*, MA, MT, NCR, NJ, PA, PRR, RI, SC*, VA*, VT, WY >17 yo LA* >14 yo IL, KY*, TX* >13 yo AZ*, MN, OH* >12 yo DC* >11 yo IN*, ND >7 yo OR >6 yo ID, WI >3 yo CA AL, AK, CO, DED , GAR, MI, MS, MOR, NE, NV, NM, OK, SC, SD, TN, UT, WA No Age Limit Updated July 2016 *Younger ages under prescription/protocol R Requires a prescription D Any age with an adult dose 27

Pharmacist Administered Vaccines Authority to Administer Hep. B Vaccine WA MT ND OR ID WI AZ CO IN OK AL MA RI CT NJ DE VA DC NC TN MS NH MD KY AR TX OH WV MO KS AK MI PA IL NM NY IA NE NV CA VT SD WY UT ME MN SC GA LA FL HI Pharmacists can administer Hepatitis B PR Pharmacists can administer Hepatitis B – but only by Rx Pharmacists cannot administer Hepatitis B Updated July 2016 28

Pharmacist Administered Vaccines Patient-Age Limitations – for Hep B Vaccination Based upon APh. A / NASPA Survey of State IZ Laws/ Rules Number of states / territories >18 yo >17 yo >14 yo >13 yo >12 yo >11 yo >7 yo >6 yo >3 yo No age limit 20 1 3 3 2 1 1 2 1 0 5 10 15 16 20 >18 yo AR*, CT, FL, HI*, IA*, KS, ME, MD*, MA, MT, NCR, NJ, PA, PRR, RI, SC*, VA*, VT, WV, WY >17 yo LA* >14 yo IL, KY*, TX* >13 yo AZ*, MN, OH* >12 yo DC*, MO* >11 yo ND >7 yo OR* >6 yo ID*, WI >3 yo CA* No Age Limit AL, AK, CO, DED, GAR, INR, MI, MS, NE, NV, NM, OK, SD, TN, UT, WA Updated July 2016 *Younger ages under prescription/protocol R Requires a prescription 29 D Any age with an adult dose

Mitchel C. Rothholz, RPh, MBA Chief Strategy Officer American Pharmacists Association 2215 Constitution Ave, NW Washington, DC 20037 Email: mrothholz@aphanet. org Phone: 800 -237 -2742 (APh. A) ext 7549 (DC Office) 202 -429 -7549 (PA Office) 267 -932 -8386 (cell) 202 -497 -5350 or 703 -201 -6070 (FAX) 202 -429 -6300 Website: www. pharmacist. com