Formulary guidance and transparency from P&T to point of care

Radar On Market Access: First Round of Vaccines Are Expected to Be Free to the Public

Posted by Leslie Small on Dec 15, 2020


With FDA issuing emergency use authorization to the coronavirus vaccine from Pfizer Inc. and BioNTech last week and Moderna Inc.'s offering not far behind, in the coming months there will undoubtedly be a variety of vaccines being administered to Americans, AIS Health reported. But who will be paying for them?

"In the case of the COVID-19 vaccine, there is a very simple take-home message, which is that no one going to get the vaccine will be charged for the vaccine or its administration, no matter what type of insurance they have, or whether they have insurance at all," Karyn Schwartz, a senior fellow at the Kaiser Family Foundation (KFF), said during a Dec. 3 web briefing.

The U.S. government has already paid for initial doses of coronavirus vaccines, and those doses will be provided for free to providers who will not be allowed to charge consumers for them — though they can bill insurers or the government for administering the vaccine, Schwartz said.

In addition, "some of the usual rules that govern vaccine coverage for people with insurance have been strengthened for the COVID-19 vaccine," she added.

The Affordable Care Act requires most group and individual market health plans to cover any vaccines recommended by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) without cost sharing, according to a recent KFF issue brief. The federal Coronavirus Aid, Relief, and Economic Security Act builds on that by requiring non-excepted group and individual plans to cover a coronavirus vaccine without cost sharing 15 days after it is recommended by ACIP. CMS also released an Interim Final Rule with Comment Period on Oct. 28 clarifying that even vaccines administered out-of-network must be available without cost-sharing.

ACIP voted to officially recommend the Pfizer/BioNTech vaccine on Dec. 12. The panel is expected to do the same for Moderna if its vaccine is granted an EUA, which means payers won't be allowed to decide not to cover one over another, Jennifer Kates, KFF's senior vice president and director of global health and HIV policy, tells AIS Health.

People with Medicare, Medicaid and the uninsured, meanwhile, will also be able to access the government-purchased vaccines free of charge, according to Schwartz.

Subscribe to the MMIT blog for more pharma, provider, and payer perspectives on key topics that affect the healthcare network.

Subscribe for Weekly Perspectives

Topics: Industry Trends, Market Access, Product Release, Payer