On a cool October morning during the fall harvest, Casey Villhauer, PharmD, drove through the plains of northwest Iowa. Yellow and green crops rolled outside the windows of her Chrysler minivan. After an hour-and-a-half journey, her tires ground into the gravel drive up to the main house of a large commercial corn and soybean farm. She stepped down from the van; grabbed shoe covers, an iPad, and a large, insulated black-and-white bag filled with flu shots and emblazoned with the VaxiTaxi.com logo; and approached the farmhouse.

In a state that’s 43% rural, Vaxi Taxi provides a critical service: home delivery and administration of any FDA-approved adult vaccine and most pediatric ones. Villhauer, the CEO and founder, describes the startup as “the Uber Eats of vaccines.” Customers—or, in this case, patients—order the vaccine they need online from VaxiTaxi.com. For a flat delivery fee, starting at $60 and depending on how far the pharmacist must travel, a pharmacist/immunizer brings the shot right to patients’ doors and into their arms. Based on the patient’s location, the order may go out to one of the mom-and-pop drug stores in the region, where Villhauer has trained and equipped 25 pharmacists and counting to carry out the service. Or Villhauer, who has registered her minivan as an independent pharmacy, may do the job herself.

At that northwest Iowa farm, Vaxi Taxi had answered the call of the elderly property owner, who needed a flu shot. After Villhauer finished with him, she stepped out into the yard, where several men were at work on a tractor. With flu shots to spare in her insulated bag, she offered to immunize the farm workers too. For one, she climbed up inside the cab of the tractor to deliver the inoculation.

The COVID-19 pandemic inspired scores of businesses to add home delivery to their service offerings. But for a pharmacist to deliver health care to the home, it’s not as simple as just marketing the service: There are many hoops to jump through.

Pharmacists’ authority to deliver health care services varies from state to state. And even with legal authority to provide a number of services, insurance companies often would rather pay other health professionals, such as a nurse or physician assistant, to provide the service.

“Home health isn’t an area that pharmacists have traditionally ventured into because it isn’t reimbursed well—or at all—for us. But I hope this service will become a long-term opportunity for pharmacists," Villhauer says.

Villhauer dreamed up Vaxi Taxi before the COVID-19 pandemic, but she had to wait for a law, which she knew was in the works in the Iowa state legislature, to take effect. The bill, which passed in 2017 and took effect in 2019, gives Iowa pharmacists the authority to order and administer any FDA-approved adult vaccine and, for children ages 6 months to 17 years, all but the first dose of the HPV shot, without a doctor’s prescription.

“As soon as the law changed, I knew I had to do this now,” Villhauer says. Taking a leap of faith, she put down her own money to start the business, and Vaxi Taxi was up and running for the 2020–2021 flu season.

But the fact that Iowa pharmacists can now administer most vaccines doesn’t mean any patient can use them. Pharmacy benefit managers prevent it in many cases. These third-party administrators—like CVS Caremark, Express Scripts and OptumRx, to name the largest—that manage health plans’ prescription drug benefits dictate where members can and cannot get a vaccine. And many of them exclude independent pharmacies from their provider networks.

In the face of these restrictions, at first Villhauer found herself providing flu shots mostly to needle-phobic kids whose parents were willing to pay out of pocket to have their skittish children vaccinated in the comfort of their own homes. Parents would pay cash for the shot plus the home delivery fee.

Villhauer would show up with a bag of tricks meant to keep the kids calm. But once the pandemic started, and demand skyrocketed for home delivery of anything and everything, kids were no longer her primary clientele.

“After just a few months of operations, overnight the demand for our service was through the roof. We were suddenly getting hundreds of voicemails, and not just from Iowa, from people asking if we could come,” Villhauer says.

To help meet demand, Villhauer enlisted independent pharmacies across the seven rural counties surrounding Des Moines. At a time when mom-and-pop drug stores are fighting to stay open throughout rural America, the partnership with Vaxi Taxi provided some much-needed cash flow.

For years, indie drugstores have struggled under the crushing restrictions of pharmacy benefit managers. They force beneficiaries to literally drive past the local drug store and get prescriptions filled at a major chain (no matter how far away) or through mail-order services.

From 2003 to 2018, rural America lost 16% of its independent pharmacies. That’s some 1,230 drugstores in areas where the next pharmacy, or even the next health care provider, could be more than an hour's drive away. According to the Rural Policy Research Institute, some 630 rural communities that had at least one drug store in 2003 had none by 2018. Rural independent shops now number fewer than 6,400 nationwide.

With the pandemic generating a client base willing to pay cash for vaccines brought to their homes, Vaxi Taxi offered rural drugstores a new way to meet that demand. For a one-time startup fee, struggling shops that may not be able to afford to start their own vaccine delivery services from scratch can join the Vaxi Taxi network. These drugstores collect cash payment for the vaccines and keep a portion of Vaxi Taxi’s delivery fee.

Vaxi Taxi trains the pharmacists to do home administration of shots and provides them with all the equipment, supplies, and software support needed to carry out the job. The software is similar to what Uber and Grubhub drivers may use, but Vaxi Taxi’s platform factors in—among numerous other factors—the time pharmacists will need to get set up in the house based on the patient’s circumstances, give the shot, and (in the case of COVID shots) monitor the patient for 15 minutes afterward.

Less than a year after Vaxi Taxi made its maiden voyage, COVID-19 vaccines became available and Villhauer’s business got another major bump. Health plans could no longer dictate where members could get COVID shots. According to the CARES Act, which was signed into law in March 2020, they could get a COVID-19 vaccine from anywhere for free. That meant Vaxi Taxi could deliver to anyone who would pay the delivery surcharge. And some people didn’t even have to pay that.

Medicare was now willing to pay for home delivery of COVID shots for a subset of its beneficiaries: homebound patients. While these folks weren’t necessarily going out and getting exposed to COVID-19, they had family caregivers, paid help, and delivery people in and out of their homes daily.

But the windfall of new clients brought Villhauer new challenges as well.

“We hadn’t even tested this population of homebound patients,” she says. “These weren’t the kinds of patients we built out platforms for. They didn’t even have digital access.”

While Villhauer’s earliest clients—cash-payers seeking convenience—got online and ordered vaccine delivery with ease, many homebound patients did not have that facility.

Vaxi Taxi’s first delivery of a COVID vaccine was to a homebound adult who called a local pharmacy to ask about home delivery. The pharmacy then called Vaxi Taxi on the patient’s behalf.

“That first COVID vaccine was for someone who would have otherwise required an ambulance to transport them to the hospital to get the vaccine because that was the only way they traveled,” Villhauer says.

Ultimately, it wasn’t hard for Villhauer to get the word out to other homebound patients. She presented Vaxi Taxi’s services at two meetings of her state’s Immunization Coalition—part of a national network of groups dedicated to improving vaccine rates in their communities—and the referrals started rolling in.

“I didn’t have to do any more marketing after that,” she says.

Vaxi Taxi got referrals from county public health departments, the state’s 211 vaccine information line, state Medicaid and Medicare providers, and home health nursing services.

After that first COVID vaccine, Vaxi Taxi delivered thousands of COVID shots to homes across central Iowa until demand finally began to wane. Now, Villhauer and her team of pharmacist-drivers are answering calls for cash-pay vaccines that older adults failed to get during the pandemic—shingles, pneumonia, Tdap. During the summer, Villhauer expects she’ll spend her days administering back-to-school shots on a cash-pay basis.

But the health entrepreneur is hopeful that insurers will soon pay for members to get vaccines from Vaxi Taxi or wherever they please. At least a dozen states have Pharmacy Benefit Manager Reform laws in the works that would relax restrictions on where health plan members can get shots.

Several states also have laws that allow their pharmacists, like those in Iowa, to administer most all FDA-approved vaccines. “California, Illinois, Georgia, Washington,” Villhauer said, listing states where pharmacists have reached out to personally petition Vaxi Taxi to expand its services to their region.

“Those states have similar laws, pharmacists have similar authority, and I can say, we are working on it. Our goal is that we are operating in every state,” she says.

For now, Villhauer says, she is exploring partnerships and investor relationships to help make that happen.

This story was originally featured on Fortune.com

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