RSV vaccine coverage by insurer

[sammys24]

All Medicare coverage is not equal.  After being informed of the dangers of RSV in the elderly (I’m 70yo) and knowing that I was going to be traveling internationally, I made an appointment to get the vaccine.  At the pharmacy, I was told that my insurer, Aetna Medicare refused coverage.  The pharmacist told me that other insurers were covering and that maybe Aetna just didn’t have it on their formulary yet.  I checked with Aetna, and was told that I need a physician’s prescription AND it would have to go through Prior Authorization.  I am finding this to be costly, inefficient, and risk-taking when I am trying to be proactive, cost-saving, and protective.  As a retired clinical pharmacist, myself, I’m disturbed by the inequity in insurance coverage. 

[GoldenOldie1949]

Insurers who don't cover the RSV vaccine are violating the PPACA. The "shared clinical decision making" phrase in the recommendation isn't a valid excuse; even the pharmacist who gives you the shot is qualified as a health care practitioner who can make the "clinical decision" with you! And the fact that the CDC hasn't edited its slick looking PDF with the vaccine recommendations yet isn't an excuse either. They have recommended the vaccine; it doesn't matter if a graphic artist has redone a chart or not! If your insurer won't pay, contact your state's insurance regulator and also HHS Secretary Xavier Beccera's office, and tell the insurance company you're doing that. It also helps to write your local, statewide, and regional newspapers. We also need to encourage AARP leadership to speak out to HHS, CMS, and Congress on this issue. Only if we seniors speak up will these greedy corporations fulfill their obligations!

[MaryH549666]

I was just turned down for RSV vaccine at Walgreens today. They said it was not covered by Medicare or my insurance. I phoned Aetna SilverScripts and was told that there was no co-pay for the shot, but that it still would be applied to the deductible, leaving me a cost for the shot of close to $400.  In looking on the AARP website at https://www.aarp.org/health/medicare-qa-tool/what-vaccines-does-medicare-cover/ it certainly looked as if I would nave not out-of-pocket expense for the RSV vaccine.  Someone either needs to fix the AARP website article or explain to me how to get Aetna to pay the full cost of this preventative vaccine, as the article implies it will. Thanks.

[GailL1]

@MaryH549666 , @sammys24 

Here is the problem - government does not know how to handle it; CMS has to write the rules for Medicare coverage and pure and simple,  because of the way the RSV vaccine was approved, CMS doesn’t know the rules to issue as to who pays and how.

This write up from the CDC or medical professionals covers it -  The key factor here is in the 1st sentence particularly the words “using shared clinical decision-making”

New vaccines against RSV are available for adults 60 and older. CDC recommendsthat adults 60 and older may receive an RSV vaccine, using shared clinical decision-making. The decision to vaccinate an individual patient should be based on a discussion between the healthcare provider and the patient. It may be informed by the patient’s risk of severe RSV disease and their characteristics, values, and preferences; the healthcare provider’s clinical discretion; and the characteristics of the vaccine.

So your doctor has to agree that you are within one of the groups that needs it - and that could be tricky.  Then the RX script from the doc has to be taken to your Part D coverage pharmacy for injection.  Then they bill your Part D plan and yes, it goes by your deductible and copay.  

Vaccines are broken down into those covered by Part B and those covered by Part D - Part B vaccines are usually covered by Medicare plans with no added out of pocket like the annual flu shot.

Then others are covered by a beneficiary’s Part D plan - some of these by law have no out of pocket expenses to be beneficiary since Medicare pays the insurer more for this coverage - like the Shingles vaccine starting this year.  However, even though other Part D vaccines are covered,  they are not covered at the same level and there are deductible cost and copays to be paid according to your Part D plan.  If you have no Part D plan, you don’t have any coverage for these Part D vaccines.

I think Medicare (CMS) and the Part D insurers are now trying to figure out how this is gonna work with these new RVS vaccines (there is more than one maker).  

CDC:  Last Reviewed 08/04/2023 - FOR Healthcsre Professionals - RVS

So to answer both of you - the RVS vaccine maybe covered ( that depends on your doc). but not 1st dollar coverage.  Right, this vaccine is not like other vaccine coverage right now.

CDC:  07/24/2023 Respiratory Syncytial Virus (RSV) VIS

[MaryH549666]

So my doctor recommended the RSV vaccine. Hopefully they will sort out the RSV issue soon and treat it as they do the flu and pneumonia vaccines - that is, Medicare covers the costs. Otherwise, I won't be getting the vaccine.

She also recommended the Shingles vaccine. The Shingles vaccine costs (with Good RX) $200 per shot just for the vaccine at the cheapest pharmacy in the area, not including the services of someone to inject it. One needs to have two shots over a period of months. So I would be looking at roughly  $500 for the Shingles Vaccine if I have to pay out-of-pocket for it. If the deductible on my Part D (SilverScripts) is involved,  the deductible is $505 per year. 

I'm also at risk for Shingles, so I'd really like to be able to follow my doctor's advice and get that vaccine as well, but there's no way I can pony up $500 cash for it. And, of course, I'm just over the limits for all financial aid programs. I'd say I'd just stay masked and never go out of my house (deja vu!). That would work for RSV-avoidance, but since I'm carrying the shingles virus around with me, it won't help me to become a hermit.  My grandmother had shingles, and I remember how miserable she was. I don't want it.

[GailL1]

Here is the 2023 list from the CDC on those recommended for the Medicare age group.

CDC 2023 Recommended Vaccines for Adults.

Medicare covers the ones recommended for the entire age group with No out of pocket as long as the beneficiary has the coverage - either Part B or Part D depending on which Part covers any specific vaccine.

For the ones where a doctor has to prescribe it because the beneficiary has to be in some risk, those are treated as a medical expense, including pharma.

[GailL1]

@MaryH549666 

The Shingrix vaccine for the shingles has a different ACIP / CDC approval - so it is completely covered by Medicare with NO out of pocket cost - both shots to complete the Shingles vaccine - Shingrix.

The Inflation Reduction Act created the rule that Starting in 2023, patients with Medicare drug plans will pay nothing out-of-pocket for adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP).  Shingrix has this complete approval.  

So sign up to get the shingles vaccine IF you have a Medicare Part D plan.

The diffence is that the RSV vaccine isn’t recommended for everybody on Medicare - there are qualifiers for it.  Thus the ACIP approval is different for the different vaccines.

[sammys24]

Gail:   I disagree.   I don’t have issues with the CDC or Medicare.  I do have an issue with Aetna (an insurance company).  Would they rather cover my treatments if infected by RSV or pay the upfront cost to PREVENT? You would think this would be an easy decision for an entity that basically bets on risk.  Aetna has to compete with other insurers and it’s only a matter of time before they will have to step up or risk losing customers. 

[GailL1]

The rule is that Starting in 2023, patients with Medicare drug plans will pay nothing out-of-pocket for adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP).

PROBLEM IS:  ACIP approved the RVS vaccine with a caveat - so that makes it different in coverage. It is NOT like other vaccines - 

I will assume that Aetna is your MAPD insurer - so with that in mind, they can establish the details (managed care) for getting the vaccine since the FDA approval wasn’t point blank for everybody over 65.  - You get an RX from the (Aetna) medical provider - the medical provider gives a medical reason for your needing the vaccine.  

That’s how the vaccine was approved by the ACIP and CDC - guess your doc would know which one to prescribe - think there are 2-3 different ones.

Here is the recommendation from the HHS Secretary

HHS.gov 06/29/2023 - Statement from HHS Secretary Xavier Becerra on CDC's Historic Recommendation Al...

Perhaps a review of ACIP Shared Clinical Decision-Making Recommendations would also help to shed some light on this  bureaucratic nightmare.

From the link:

How do shared clinical decision-making recommendations differ from routine, catch-up, and risk-based immunization recommendations?

Unlike routine, catch-up, and risk-based recommendations, shared clinical decision-making vaccinations are not recommended for everyone in a particular age group or everyone in an identifiable risk group. Rather, shared clinical decision-making recommendations are individually based and informed by a decision process between the health care provider and the patient or parent/guardian.

Hey don’t shoot me - I am just the messenger NOT THE DECISION MAKER.

Like other things in government, the message gets real scrambled to the public.