Pharmacist Ani Martirosyan administers an immunization to a patient at a CVS on Tuesday, Sept. 12, 2023 in Glendale, CA.
Brian Van Der Brug | Los Angeles Times | Getty Images
The rollout of a new round of Covid vaccines in the U.S. is encountering obstacles as some patients report delays in health insurance coverage for the shots.
Private insurance plans and government payers, including Medicare, are mandated to cover the new vaccines from Pfizer and Moderna, which recently became available. U.S. regulators have recommended that all Americans ages 6 months and older receive the new vaccines.
The Centers for Medicare and Medicaid Services, CVS, and other healthcare providers have acknowledged the temporary delays in coverage. They have emphasized that Covid vaccines can still be accessed at no cost through insurance plans. The delays are due to insurers updating their plans to include the new vaccines.
Several posts on social media in recent days reveal that some patients have been charged $125 to $190 for the vaccine at pharmacies, while others have been informed that their insurance plans do not yet cover the new vaccines.
These reports are causing confusion among insured patients, despite reassurances from public health officials that they can still access Covid vaccines for free. This confusion arises at a time when Covid cases are increasing nationwide.
This situation follows a significant change in how Covid vaccines are covered in the U.S. Manufacturers now sell the vaccines directly to healthcare providers at a price exceeding $120 per dose, as the government shifts the responsibility to the commercial market. Previously, the federal government obtained the vaccines at a discounted price and distributed them to Americans for free.
A spokesperson for the Centers for Medicare and Medicaid Services (CMS) acknowledged the difficulties some consumers have faced in accessing Covid-19 vaccines, particularly insurance coverage denials at the point of service. CMS has been in close contact with insurance plans to ensure they are up-to-date and prepared to fulfill their obligations of covering Covid-19 vaccines.
A spokesperson for CVS explained that some payers are still updating their systems and may not yet be prepared to cover the updated COVID-19 vaccines. In cases where coverage is denied, CVS pharmacy teams can help patients schedule a vaccine appointment for a later date.
Sarah Lindsey, owner of a Florida-based jewelry store, publicly urged her insurer, Florida Blue, to include the new Covid shots in its formulary. She reported that insured members attempting to obtain the vaccine at a pharmacy have been told it is not approved and will cost $155. Florida Blue advised patients who were charged for the vaccine to contact their pharmacy for reimbursement or file a claim with the insurer.
Elevance Health, a healthcare provider, encouraged pharmacies to resubmit Covid vaccine claims so that they can be processed with a $0 copay.
These insurance coverage issues arise at a time when the uptake of the new Covid vaccines is already a concern. Pandemic fatigue, the belief that Covid is over, and confusion over personal risk levels may impede the adoption of the vaccines, which target the omicron subvariant XBB.1.5.
According to the Centers for Disease Control and Prevention, only 17% of the U.S. population, approximately 56 million people, have received Pfizer and Moderna’s bivalent Covid boosters since their approval in September last year.
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