An Update on State-Level Authority on Pharmacy Immunization

During the COVID-19 pandemic, the federal Public Readiness and Emergency Preparedness (PREP) Act consistently expanded the authority for pharmacists, technicians, and interns nationwide to administer COVID-19 vaccines to those 3 years and older. It was subsequently expanded to include all routine pediatric vaccines. Set to expire in 2024, it was extended in December 2024 to 2029.¹ As this provision will eventually sunset, states must make this authority permanent in state law. This state-by-state variability poses a significant barrier for providers striving to deliver care and patients seeking convenient access to essential vaccinations. Understanding these post-PREP implications is therefore not just academic; it is critical for evaluating current public health delivery, identifying ongoing access, and informing future policy.²

Understanding post-PREP implications is critical for evaluating current public health delivery, identifying ongoing access, and informing future policy. | Image Credit: fotofabrika - stock.adobe.com

Pharmacy-Based Immunization, Before vs After Pandemic

Before the PREP Act, pharmacist vaccination authority lacked uniform national standards and varied widely by state. According to the June 2020 American Pharmacists Association (APhA)/National Alliance of State Pharmacy Associations (NASPA) survey, 47 states allowed pharmacists to administer any vaccine, with most of those states using a combination of protocol or prescription requirement with age restrictions.³ There are 3 primary models in which pharmacists are authorized to administer immunizations: prescription from another provider, patient-specific or state vaccination protocol (aka collaborative practice agreement), or independently without a prescriber’s order or protocol. As of January 2025, all 50 states allow pharmacists to administer any Advisory Committee for Immunization Practices (ACIP)/CDC–recommended vaccine.⁴ State laws still impose diverse restrictions on vaccine types and varying minimum age limits, and the model used to authorize pharmacists creates a regulatory patchwork.

For example, in Texas, pharmacists can give the influenza vaccine to those 7 years and older, 14 years and older for other vaccines pursuant to a protocol, and any age with a patient-specific protocol. Pharmacy-based immunization is moving in the right direction, but without the federal PREP Act framework, we will continue to have a patchwork of state-based laws. The authorization granted for pediatric vaccination has not advanced as far as adult vaccination.

According to the APhA/NASPA 2024 data, only 19 states plus Washington, DC, allow pharmacists, independently or by protocol, to administer all ACIP-recommended vaccines to those 3 years and older.⁴ This includes states with no minimum age. Research demonstrates that allowing pharmacists to vaccinate children increases vaccination access and uptake, particularly in underserved and rural areas, without delaying other aspects of preventive care such as well-child visits.^5-7 Parents report a strong willingness to have their children vaccinated at pharmacies, and studies show that community pharmacies can effectively serve as Vaccines for Children providers, supporting public health goals by improving human papillomavirus and COVID-19 vaccination rates among children and adolescents.^5,6,8 Expanding pharmacist authority in pediatric immunization can help close gaps in vaccine coverage, reduce missed opportunities, and enhance public health preparedness.^7,8

Pharmacy Technician Vaccination Roles

Pharmacy technician vaccination authority is not uniform across states and remains typically more limited and restricted than the authority granted to pharmacists. States may limit the types of vaccines technicians can administer, with seasonal influenza and COVID-19 being the most common. As of January 2025, 47 states plus Washington, DC, allow pharmacy technicians to vaccinate compared with only 6 in 2020 (Table).^3,4 A 5-year review found that US pharmacy technicians administered more than 1 million vaccines from 2016 to 2021 with no reported serious adverse events.⁹ The data showed that more than 90% of supervising pharmacists and 85% of technicians supported technician-administered immunizations, and more than 80% of patients were comfortable receiving vaccines from trained technicians. The inclusion of pharmacy technicians as vaccinators represents a significant strategic shift that improves pharmacy workflow efficiency, safely expands vaccination service capacity to reach more patients, increases pharmacist clinical time for complex patient care activities such as medication therapy management and counseling, and enhances technician job satisfaction, all without compromising patient outcomes.^9,10

State Authority: FDA, CDC, ACIP

State authority for who can administer vaccines is not directly granted or dictated by the FDA, CDC, or ACIP. Instead, individual states determine a pharmacist’s and a technician’s scope of practice. The FDA is responsible for licensing vaccine products, ensuring their safety and efficacy for specific uses through rigorous review processes. The CDC and its advisory committee, ACIP, are responsible for developing and adopting clinical guidelines and recommendations on how and to whom vaccines should be administered based on scientific evidence and public health needs.¹¹ The recent viewpoint in JAMA of past ACIP members warns that the abrupt dismissal and replacement of ACIP members in June 2025 could erode public and professional confidence in future ACIP recommendations, potentially diminishing their influence on US vaccine policy and uptake.¹²

States set requirements for education and training, specifying required levels of supervision, imposing age limits, and determining the mechanisms by which the authority is granted. The impact of the ACIP/CDC on state law illustrates that although ACIP’s guidance is nonbinding, it profoundly influences state and territorial vaccine policy. It appears in nearly 600 statutes and regulations across 49 states, 3 territories, and Washington, DC, informing school vaccine mandates, insurance coverage, provider scope, standing orders, vaccine purchasing, professions that immunize, and immunization notifications.¹³

How a state uses the FDA, CDC, or ACIP may dictate whether pharmacists must follow CDC recommendations or have professional discretion to deviate. It is important to note that if they rely on the PREP Act for expanded authority, it also stipulates that vaccines must be approved or authorized by the FDA and administered according to CDC recommendations for COVID-19 and pediatric vaccines.¹ At least 1 pharmacy organization removed its endorsement of the recent COVID-19 vaccine recommendation when it deviated from the CDC’s previous recommendation for children and pregnant women.¹⁴ A review of the 50 states plus Washington, DC, indicates that 45 explicitly mention the CDC in their statutory language, 3 mention ACIP without the CDC, and 2 do not mention ACIP or the CDC. However, of the latter two, Alaska has Board regulations that require the use of the CDC for many aspects of the vaccination process. Only Texas does not mention the CDC in regulation or statute but does indicate that the training program needs to meet CDC standards.

Thus, if the CDC/ACIP recommendations continue to deviate from scientific evidence-based recommendations, pharmacists may be constrained by the laws that regulate them. States may need to review other options to allow the pharmacist the most professional discretion, such as broad standard-of-care models,¹⁵ new legislation, or other state-specific remedies.

Conclusion

Postpandemic pharmacy law reforms have expanded independent vaccination authority for pharmacists, widespread technician vaccination privileges, and lower age restrictions for pediatric immunization. The shift from physician protocols to streamlined authority and statewide standing orders improved efficiency and accessibility. The PREP Act’s temporary provisions accelerated these changes, but as authority returns to states, significant variability and reliance on CDC recommendations persist. For long-term resilience, states should grant pharmacists greater autonomy to determine and implement the most appropriate vaccine recommendations for their patients, ensuring continued broad access to lifesaving immunizations.

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REFERENCES

1. 12th amendment to declaration under the Public Readiness and Emergency Preparedness Act for medical countermeasures against COVID-19. 89 CFR §99875 (2024). https://www.federalregister.gov/d/2024-29108

2. Wayne SK Jr, Barenie RE. The dilemma of childhood vaccines post pandemic. Pharmacy Times. October 25, 2024. Accessed July 8, 2025. https://www.pharmacytimes.com/view/the-dilemma-of-childhood-vaccines-post-pandemic

3. National Alliance of State Pharmacy Associations, American Pharmacists Association. Pharmacist-Administered Vaccines. Updated June 2020. Accessed July 8, 2025, https://naspa.us/wp-content/uploads/2019/04/Pharmacist-Administered-Vaccines-June-2020-Final.pdf

4. Pharmacist and pharmacy technician vaccination authority. September 3, 2024. Accessed July 8, 2025. https://naspa.us/blog/resource/2024-pharmacist-immunization-authority/

5. Daniel CL, Lawson F, Vickers M, et al. Enrolling a rural community pharmacy as a Vaccines for Children provider to increase HPV vaccination: a feasibility study. BMC Public Health. 2021;21(1):1266. doi:10.1186/s12889-021-11304-8

6. Varisco TJ, Downs CG, Sansgiry SS, Al Saadi R, Hastings T, Thornton JD. Parents’ intention to have their child vaccinated at a community pharmacy: a national cross-sectional survey. J Am Pharm Assoc (2003). 2023;63(2):511-517.e8. doi:10.1016/j.japh.2022.10.008

7. Bhardwaj S, Galanter N, Berenbrok LA, Shah PD, Bacci JL. Pediatric vaccination in pharmacies is not associated with delayed well-child visits among commercially insured children. Health Aff Sch. 2025;3(2):qxaf028. doi:10.1093/haschl/qxaf028

8. Kim C, Yee R, Bhatkoti R, et al. COVID-19 vaccine provider access and vaccination coverage among children aged 5-11 years - United States, November 2021-January 2022. MMWR Morb Mortal Wkly Rep. 2022;71(10):378-383. doi:10.15585/mmwr.mm7110a4

9. Adams AJ, Bright D, Adams J. Pharmacy technician–administered immunizations: a five-year review. J Am Pharm Assoc (2003). 2022;62(2):419-423. doi:10.1016/j.japh.2021.11.011

10. DeMarco M, Carter C, Houle SKD, Waite NM. The role of pharmacy technicians in vaccination services: a scoping review. J Am Pharm Assoc (2003). 2022;62(1):15-26.e11. doi:10.1016/j.japh.2021.09.016

11. ACIP charter. CDC. April 1, 2024. Accessed July 8, 2025, https://www.cdc.gov/acip/about/acip-charter.html

12. Asturias EJ, Brewer NT, Brooks O, et al. Advisory Committee on Immunization Practices at a crossroads. JAMA. Published online June 16, 2025. doi:10.1001/jama.2025.10776

13. Impact of the Advisory Committee on Immunization Practices recommendations on state law. Association of State and Territorial Health Officials. June 23, 2025. Accessed July 14, 2025. https://www.astho.org/topic/resource/impact-of-acip-recommendations-on-state-law/

14. APhA withholds endorsement of ACIP adult immunization schedule. American Pharmacists Association. June 9, 2025. Accessed July 8, 2025. https://www.pharmacist.com/APhA-Press-Releases/apha-withholds-endorsement-of-acip-adult-immunization-schedule

15. Adams AJ, Chopski NL, Adams JA. How to implement a “standard of care” regulatory model for pharmacists. J Am Pharm Assoc (2003). 2024;64(3):102034. doi:10.1016/j.japh.2024.02.007