Lawmakers Seek to Address Medicare Vaccine 'Sticker Shock'

Kerry Dooley Young

June 28, 2021

Federal lawmakers from both parties are seeking to end copays for vaccines for people enrolled in Medicare Part D pharmacy plans, intending to expand the use of these medicines.

In the House, 20 Democrats and 10 Republicans have signed on as co-sponsors to the Protecting Seniors Through Immunization Act of 2021 (HR 1978), introduced in March by Rep. Ann Kuster (D-NH). The companion Senate measure (S 912) has the backing of two Democrats and two Republicans. This legislation would end copays in Medicare Part D plans for vaccines recommended for adults by the CDC's Advisory Committee on Immunization Practices.

Older Americans too often forgo vaccines due to "sticker shock" of copays charged for them, L.J. Tan, PhD, the chief strategy officer of the Immunization Action Coalition, told House lawmakers at a recent hearing.

Many people enrolled in Medicare get reminders about getting vaccines from their own adult children, who are in private insurance plans and don't have copays. But when older people enrolled in Medicare Part D plans request these same vaccines, such as shots to prevent shingles at their pharmacy, they may be faced with costly copay demands, Tan said.

"They turn away and say, `You know I can't afford that right now because I'm on fixed income,'" Tan told the House Energy and Commerce Committee's health panel at a June 15 hearing about expanding access to vaccines.

He cited research by the consulting firm Avalere that indicates the average vaccine copayment was $47, though the maximum copayment is as high as $100. Funding for the Immunization Action Coalition comes from the CDC as well as sources including pharmaceutical companies, health plans, hospitals, and foundations, according to the group's website.

The bill also calls for providing senior citizens with more clear information about vaccine coverage through the Medicare & You handbook. There's confusion among doctors and patients now about which vaccines are covered by Part B and which fall under Part D. There is no copay for shots covered by Part B, such as the COVID-19 vaccine and flu shots. But there can be ones charged for those covered by Part D, such as the shingles shot.

Drugmakers vs Insurers

There is wide support for the pending legislation to end Medicare Part D from medical and patient groups and drugmakers. The American Academy of Family Physicians and the Infectious Diseases Society of America were among the about 40 organizations that signed a March 15 letter in support of the House bill. Other signers of this letter, organized by the Adult Vaccine Access Coalition, included vaccine makers such as Pfizer, GlaxoSmithKline, and Sanofi, and the Biotechnology Innovation Organization.

But insurers take a different stance on this issue.

America's Health Insurance Plans (AHIP) submitted a letter to the House Energy and Commerce health subcommittee about the House bill. In it, the insurers' group argued that the Protecting Seniors Through Immunization Act would trigger an increase in costs of providing health care to U.S. seniors.

"We have serious concerns that H.R. 1978 includes no mechanism to protect patients from unilateral drug price increases," Matthew Eyles, chief executive officer of AHIP, wrote in the letter. "Drug manufacturers have sole control over drug pricing and increasing list prices."

The Protecting Seniors Through Immunization Act, as it is currently written, "would embolden vaccine manufacturers to raise prices without limits," he wrote. This could lead to higher Part D premiums for all seniors, while raising the cost for taxpayers.

Switch to Part B?

An influential federal panel this month suggested a different approach for expanding the use of vaccines among senior citizens.

The Medicare Payment Advisory Commission (MedPAC) included a chapter on vaccine policy in its June report to Congress. In it, MedPAC noted that Congress placed coverage of COVID-19 shots under Medicare Part B. The panel recommended that Congress move all preventive vaccine coverage to Part B, sparing people enrolled in Medicare from out-of-pocket costs for these medicines.

In 2007, MedPAC had recommended that Medicare vaccine coverage be moved to the Part B program. The Part D program then had only recently been implemented. Doctors then were concerned that the out-of-pocket cost for vaccines covered by Part D would discourage older patients from seeking the right preventive care, MedPAC wrote.

MedPAC noted that paying for the Shingrix vaccine, in particular, has been a challenge for people enrolled in Medicare who don't qualify for financial assistance. Shingrix has a median out-of-pocket cost of about $50 per dose and requires two doses given a few months apart, the panel said.

MedPAC also noted that more people are enrolled in Medicare Part B (57.3 million) than in Part D (48.8 million), which means a switch in vaccine coverage could expand access to these medicines. And the commission noted that a "wide variety of health care providers (e.g., hospitals, physician clinics, dialysis facilities) bill Medicare under Part B, offering more settings where beneficiaries can receive vaccines than under Part D."


Article: Lawmakers Seek to Address Medicare Vaccine 'Sticker Shock' "H.R.1978 -- Protecting Seniors Through Immunization Act of 2021," "S.912 -- Protecting Seniors Through Immunization Act of 2021." "L.J. Tan, MS, PhD, Chief Strategy Officer, Immunization Action Coalition, Testimony Before the House Energy and Commerce Committee Subcommittee on Health."

Avalere: "Medicare Part D Plans Continue to Require Cost Sharing for Vaccines."

Immunization Action Coalition: "IAC Funding."

Adult Vaccine Access Coalition: "AVAC Protecting Seniors Support 3_15_21."

America's Health Insurance Plans: "AHIP Statement EC Health Sub Hearing on Vaccines."

Medicare Payment and Advisory Commission: "Medicare Payment and Advisory Commission Releases Report on Medicare and the Health Care Delivery System."