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Out-of-pocket expenses for COVID-19 tests, treatments, and vaccines on horizon for patients

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Clarissa Chan, PharmD

Once the COVID-19 public health emergency (PHE) is lifted, COVID-19 tests, treatments, and vaccines will no longer be “free” for all. Patients with private insurance, Medicare, and Medicaid may experience more cost-sharing, but patients who are underinsured or uninsured will be most affected.      

“It’s easy to see that there wasn’t additional funding for testing and vaccination to offset provider costs to care for uninsured patients after the Provider Relief Fund was exhausted in March/April 2022,” said Lisa Schwartz, PharmD, RPh, referring to a Kaiser Family Foundation timeline for federal support. A few funding bills in Congress have comprised funding in response to the COVID-19 pandemic.

“This has been a challenge for [pharmacists] and other testing and vaccine providers,” said Schwartz, who is senior director of professional affairs at the National Community Pharmacists Association (NCPA).

Schwartz helped answer some pressing questions to prepare pharmacists and their communities for the changes ahead.

How will future changes to COVID-19 supply funding affect consumers?

Once vaccines and treatments are no longer purchased by the federal government, consumers will bear the cost—either with their health plan benefit (e.g., private insurance, Medicare, Medicaid) or out of their own pocket if they are uninsured.

“Consumers who have insurance will need to get vaccines from in-network providers rather than walking into any vaccine site,” said Schwartz.

Medicare Advantage is already limiting vaccine administration fee reimbursement to in-network providers, but the current vaccine supplier agreement for U.S. government-owned vaccines prohibits out-of-network providers from charging patients with this type of coverage, said Schwartz.

Will the manufacturing, procurement, and pricing of supplies change?

“I expect that the overall effect of commercialization, manufacturing, procurement, and pricing for treatments, vaccines, and supplies will be more responsive to consumer demand and health plan utilization management (e.g., prior authorization),” said Schwartz. Overall, manufacturers make different business decisions when the federal government isn’t the sole customer in the United States.

Will insurance provide limited coverage for COVID-19 products?

Schwartz expects that employer-sponsored plans, marketplace plans, Medicaid-managed care plans, and Medicare PDP and Advantage plans will use traditional utilization management tools to encourage formulary compliance if the plan has preferred products in the vaccine or treatment categories.

The cost of treatments such as monoclonal antibodies and oral antivirals will depend on plan deductibles, cost-sharing, and formulary tiers, according to Schwartz.

Will COVID-19 vaccines be 100% covered like most vaccines?

“Everything I hear points to the COVID-19 vaccine being covered at $0 copay just like most other vaccines,” said Schwartz.

Two things that may be different are checking ahead that the vaccine provider is in-network for the insurance plan and making an appointment to be sure that the provider has the correct primary series or booster dose in stock, Schwartz said.

NCPA is working with other pharmacy associations to ensure that pharmacy interns and certified technicians continue to have the opportunity to administer vaccines.

How can pharmacists help people adjust to COVID-19 cost-sharing changes?

Patients have been mostly satisfied with the shift from walk-in to appointment-based vaccine services at the pharmacy. Vaccine appointments give the pharmacy staff time to verify eligibility and coverage, and check for other vaccination gaps that could be addressed during the same appointment.

Coverage and reimbursement for treatments such as oral antiviral drugs are more wait-and-see.

“The emergency use authorization allows pharmacists to prescribe Paxlovid, but I don’t expect that will be part of the new drug application approval,” said Schwartz. “Pharmacy-based test-to-treat will revert to pharmacist scope of practice and whether the state practice act allows or would require a collaborative practice agreement with a prescriber will remain to be seen.”

Antiviral prescriber access in some states will shrink, so review dispensing records now for a potential collaborating prescriber if there is uncertainty that pharmacies will offer test-to-treat after the PHE expires, cautioned Schwartz. ■

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