NCPA's Blog - The Dose

The Dose

Pharmacist: Vaccinations an Easy Way to Boost Revenue, Help Patients

by Kevin Schweers | Jan 13, 2016

Recent Dose posts

As prescription drug reimbursement rates are continually cut by pharmacy benefit management (PBM) corporations, it's increasingly vital for pharmacies to operate profitable niches to stay afloat. Many examples are posted on NCPA's Diversified Revenue Opportunities web page, a sort of PBM-free profit zone. Establishing or expanding immunizations is one great option and is the focus of this blog post.

Tana Kaefer, PharmD, is Clinical Coordinator for Bremo Pharmacies in Richmond, Va., which operates both community pharmacy and long term care (LTC) businesses. NCPA's America's Pharmacist® magazine profiled her immunization work last summer, including how she markets immunizations, works with local physician offices and has an interesting partnership established with Janssen Pharmaceuticals regarding mental health vaccines.

We recently asked her to share her views on what's new with immunizations and what advice she would offer community pharmacies that have room to start offering immunizations or expand an existing practice.

NCPA: How is the current influenza immunization season going so far? Have you experienced any supply issues? What has been the interest this year given the fact that the influenza vaccine was only marginally effective last year?

Kaefer: It's going well. A lot of what I do is scheduling and running our offsite clinics. We do a big push before the season gets started to get most of these clinics scheduled in advance. This helps me plan my days and allocate vaccine appropriately. We offer onsite clinics at our LTC facilities and other businesses if there are 10 or more people interested in receiving the vaccination. Most of the clinics are scheduled in September and October.

We may have had less walk-in business this year at our retail locations. I can't say for sure that it's attributable to match concerns. Some patients discuss that. When it does come up I've used the opportunity to tell people that the reports are that the match is better this year and the flu vaccine remains to be the best protection we have against the flu.

This year everyone over 65 wanted the high-dose vaccine. So there has been higher demand for it than in years past. There also was a delay in the shipment of the intranasal vaccine, so that caused some issues early in the season.

NCPA: Do you offer all types of influenza vaccine? How did you decide how much of each to order?

Kaefer: I learned very early not to put all my eggs in one basket. Sometimes one manufacturer can have production problems so I try to diversify my flu vaccine profile so to speak.

I usually try to limit it to three types of injectable vaccine to help keep it simple for our pharmacists. The age differences and excipients can be confusing, so we make a chart every year to help avoid any errors. This year we ordered mostly quadrivalent, which protects against four strains of influenza. We also ordered the high-dose and intranasal.

People seem to be paying attention to the differences between vaccines, such as quadrivalent versus trivalent [three strains]. Patients seem to know more, perhaps due to education by our pharmacy staff or advertising. Some people ask "Is this the one with all the strains? Or "Is this the super potent flu vaccine for older people?"

I order vaccine based on last year and what my company customers (group homes, businesses, etc.) want. For example one of the businesses I provide vaccines for wanted the nasal vaccine, but there were shipment delays and we needed to use the injectable vaccines instead. The nasal version I ordered came in later. I was worried about being left with excess. Then word got out that Bremo had nasal, and people flocked there to get it.

NCPA: Are flu shots mandatory for your employees?

Kaefer: They are not mandatory for pharmacy staff. But we offer them free of charge [to pharmacy staff], so most take advantage of it.

NCPA: What would you say to a fellow independent community pharmacist who does not offer immunizations in their pharmacy?

Kaefer: Call me, it is a much easier process that you might think. I understand that starting an immunization program can seem overwhelming and certainly be stepping out of your comfort zone. But once you make the commitment, it is so easy. There are many free resources available, so you would not be starting from scratch. The most challenging part would probably be finding a provider to collaborate with. However, as independent pharmacies you most likely already have strong working relationships with doctors and other providers in your area. There is also nothing wrong with starting slow, for the first year offer influenza and pneumococcal vaccines. From there you can get your feet wet and decide if expanding to include more vaccines is an option for your business.

Once your protocol is in place, you do have to plan ahead to ensure you will have vaccine in a timely manner for the upcoming season. I'm getting ready to order vaccines now for the next flu season, even though the current season is not over. But even if your timeline doesn't allow this advance planning, don't let this stop you. Order what you can, and set goals for future influenza seasons.

I'm also a big advocate for getting students involved and helping. They can help develop protocols. There are also multiple helpful resources at They have developed standing protocols for many of the immunizations that are ready to be printed and used. They also have helpful screening forms and other tools that are ready to go. I'm very excited about increasing immunization rates and I've shared our protocol with several other pharmacies in VA. I don't see it as competition, but rather a way to help more patients have access to care.

NCPA: What resistance or biggest problems did you encounter when starting (or expanding) your practice? And how did you overcome those? Do you offer offsite immunizations to employer groups? Have you partnered with any physician groups?

Kaefer: The biggest problem is when I do offsite clinics and patients have a different insurance than what I'm expecting. It can be hit or miss whether the insurance will cover it and I won't know until I get back to the pharmacy and run the claim. It is rare that insurance will not cover the influenza vaccine, but I make sure the patient knows they may be responsible for the cost in the event it is not covered.

When scheduling off-site clinics, I usually target employers that I know whose insurance covers the flu shots.

The pre-planning for the off-site clinics is key and I have my procedures down to a science I provide all of the screening forms and vaccine information sheets ahead of time. This allows patients to fill out the forms in advance of the clinic and patients are told to bring their insurance card. We arrange appointment times for everyone and they're out in less than three minutes. This minimizes work interruptions and helps eliminate the "I don't have time for my flu shot" excuse. The H.R. people love it.

In addition, recently when we go out to do flu clinics we started taking other vaccines that were appropriate for certain patients as well and we knew in advance their insurance would pay for it. We routinely screen for pneumococcal and herpes zoster vaccines and if patients are eligible and meet the screening criteria we will provide these vaccinations as well. Again this helps increase vaccination rates and minimizes work place interruptions.

We also partner with some physician groups. We will either sell the vaccine for them to administer or we will provide clinics at the offices for staff if this is more convenient.

NCPA: In some areas the national chain pharmacies and supermarkets heavily market their flu shot offerings. Is that true where you live?

Kaefer: Absolutely there is high competition locally. We don't compete with big chains. We get customers who know we can accommodate walk-ins very quickly without a wait like they might have at the chains. It's working pretty well.

NCPA: Have you noticed any change with regard to health insurance plans covering pharmacist-administered immunizations? Can you give a rough approximation of how many do cover it? Do any plans cover immunizations only under the medical benefit? If so, are you able to bill for these?

Kaefer: Yes. A hand full of insurance plans only cover immunizations under the medical benefit [rather than through the drug plan]. We do not jump through hoops to bill for this. We bill the patient and offer them documentation so that they can file for reimbursement. This seems to work for most folks. In our LTC practice, Virginia Medicaid unfortunately won't pay an administration fee—only the cost of the vaccine. While we hope this will change in the future, we still administer flu vaccine to these patients because we believe it is the right thing to do.

NCPA: What role do technicians play with respect to your program?

Kaefer: Techs play a huge role in advocating and interacting with patients, asking "Have you had your flu vaccine?" We created a form for flu season to help our pharmacists and technicians to know which other shots the patients may be eligible for. Pneumonia vaccine may be appropriate for patients who smoke or have asthma, etc. Or if the patient is over 50, we ask if they've had Zostavax.

The form leads you through what vaccinations the patient may be eligible for and allows the techs to be able to help with that and ask the questions so I know when it gets to me what other vaccines the patient may be interested in. Techs also help get all the immunizations ready for administration.