Here are the key points

1. The federal government will purchase the vaccine and allocate supply to the states for prioritized distribution.
2. During this time, the federal government will cover the ingredient cost of the vaccines, but non-grandfathered plans will be required to cover the administration costs charged by health care providers and facilities without cost sharing.
3. Coverage must begin within 15 business days of approval by the director of the CDC of a recommendation from the CDC’s Advisory Committee on Immunization Practices.
4. During the Public Health Emergency period, non-grandfathered plans are also required to cover these charges out-of-network and pay a “reasonable” rate to the out-of-network provider. Medicare rates will be considered reasonable.

Have questions about these action items? Contact us.

Other key points

Self-insured plan sponsors will also need to determine whether to cover this in their medical or pharmacy benefits.

Segal is recommending coverage in both settings to maximize access and minimize member confusion. When covered in the medical benefit, there may also be an office visit charge if received in an office setting.

Plans should review current plan documents detailing how other vaccines are currently covered and determine if any amendments to plan documents may be required.

Please work with your compliance expert to review plan documents. Grandfathered plans are not required to cover the vaccine (with or without cost sharing), but will likely choose to do so (or the terms of their plan may require them to do so), and must make similar coverage decisions to non-grandfathered plans.

Because of the handling issues (extreme cold storage for some vaccines) and other distribution issues, the vaccine is likely to be provided by major pharmacy chains and hospital based outpatient facilities.

We expect that administration sites will vary by state and will change over time as new vaccines are approved (e.g. some vaccines have less stringent handling requirements).