With the apparent rapid review and approval of multiple COVID-19 vaccines by the FDA, there are still aspects that need to be ironed out; however, the rollout will be applied in phases. With the first healthcare workers in the U.S. receiving the vaccine on December 14, 2020, the supply chain will continue to evolve as more vaccines become available. There will be a phased approach regarding who will be eligible to get vaccinated first:

Phase 1: High-risk workers in healthcare facilities, first responders, older adults living in senior care centers, and those with underlying or comorbid conditions that expose them as a higher risk.
Phase 2: Essential workers, teachers/school staff, people in homeless shelters or group homes for individuals with physical or mental disabilities or in recovery, people in prisons/jails/detention centers, and those with underlying or comorbid conditions that expose them with moderate risk.
Phase 3: Young adults, children, essential workers not included in Phase 2.
Phase 4: Everyone residing in the US who did not receive the vaccine in Phase 1, 2, or 3.

Source: National Academy of Sciences, Discussion Draft of the Preliminary Framework for Equitable Allocation of COVID-19 Vaccine

Mandates for the Vaccine

While there is no federal mandate that everyone residing in the U.S. get the COVID-19 vaccine, there are sure to be legal opinions on both sides for employers mandating the vaccine for their employees. Hays Companies continues to monitor the progress of the vaccine approval timeline, the phased rollout, as well as the legal stances on the topic of employer mandates on vaccination.

Vaccine Cost

The way this has been presented to America is that the U.S. Government will pay for the actual vaccine but the cost of the administration of each respective vaccine will most likely have to be picked up by the recipient’s medical plan coverage. Speculative estimates have put the cost of that administrative charge to be in the $15 – $45 range. The vaccine manufacturer that each provider or healthcare system contracts will most likely be a major determining factor in the administrative fee to the providers and administration charges.

The Employer Role

The CARES Act requires almost all individual and employer sponsored group health plans to cover the administration of the vaccine without cost sharing. This is true even if an individual gets vaccinated by an out-of-network provider. Hays Companies is researching how the administrative charge will be applied when someone does not have medical insurance coverage.

Vaccine Dosage

The vaccines will come in one dose or two doses depending on the manufacturer. It is doubtful that members will have the choice between the two methods of administration. Which vaccine an individual receives will depend on what vaccine the facility or health system is administering.

More information will become available as the vaccine becomes increasingly available.

Carve-Out PBM COVID-19 Vaccine Considerations

A pharmacy benefit manager (PBM) carve-out means that the pharmacy benefit is not integrated directly with the medical benefit.

Many of our clients with a carved-out PBM have been receiving notifications from their respective PBMs advising that, unless they specifically opt-out, the COVID-19 vaccines will be added to their formularies. This means that the vaccines would then be eligible to be filled through the Rx benefit. Since the vaccines will be available for $0 member cost, there is no driver for members to fill through either channel. The main goal is to have this available to any and all members with as few barriers as possible. Since the member share will not vary wherever they receive the vaccine, we currently do not find issue with the COVID-19 vaccines being covered by both medical and Rx on a carve-out scenario.

For groups that have their PBM carved-in, meaning it is integrated benefit with medical, these will most likely still just adjudicate through the medical plan. Given that the medical carrier and the PBM are directly integrated, it is speculated that claims should be processed without issue.

While it currently seems unlikely that there being any issues for processing COVID-19 vaccines through a carve-out PBM, clients may run the risk of having the coverage communication between their medical carrier and carve-out PBM hit a snag if coverage is only offered through the medical benefit.

With the current information known, it is recommended to not opt-out of having these vaccines added to the PBM formulary (i.e. they should allow them to be added) to avoid any potential hiccups in getting the claims processed and the members vaccinated.

Planning Ahead

The chart below, provided by the U.S. Department of Health and Human Services, outlines a potential view of the vaccine and key factors in each phase.


Source: U.S. Department of Health and Human Services, From the Factory to the Frontlines

Hays Companies is actively monitoring legal considerations, vaccine rollouts and changes in federal guidance. As more vaccines become available, we will be identifying vendors for onsite vaccine clinics, creating templates for employee communication and ensuring you and your employee population are equipped to confidently approach the vaccine.

Please be advised that any and all information, comments, analysis, and/or recommendations set forth above relative to the possible impact of COVID-19 on potential insurance coverage or other policy implications are intended solely for informational purposes and should not be relied upon as legal or medical advice. As an insurance broker, we have no authority to make coverage decisions as that ability rests solely with the issuing carrier. Therefore, all claims should be submitted to the carrier for evaluation. The positions expressed herein are opinions only and are not to be construed as any form of guarantee or warranty. Finally, given the extremely dynamic and rapidly evolving COVID-19 situation, comments above do not take into account any applicable pending or future legislation introduced with the intent to override, alter or amend current policy language.

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