Top 3 Things You’ll Learn
- The emergency health measures for COVID-19 are ending – don’t panic
- The government supply of vaccines and anti-virals will fill claims until it is emptied
- Key lessons from the pandemic we can’t forget moving forward
More than three years after they were declared, the national and public health emergencies for the COVID-19 pandemic are ending. As plan sponsors face new questions about pharmacy benefit coverage, benefit advisors need to understand what’s changing, what’s still up in the air, and the essential takeaways from the past few years of heightened viral awareness.
What changes after the COVID-19 emergencies end?
The emergencies declared in 2020 impacted pharmacy benefit plans, and some of those mandated coverage changes will end when the emergencies do. Under the national emergency, members had extra time to sign up for COBRA coverage, make premium payments, file appeals, and submit external reviews when given an adverse benefit decision. President Biden signed a congressional resolution to end that measure on April 10, 2023. While the national emergency has ended, the extended timelines will continue through July 10, giving members and plan sponsors time to adjust and finalize in-progress claims. Benefit advisors should ensure their clients are aware of the timelines.
Other aspects of the public health emergency will end on May 11, 2023, and benefit advisors should keep their clients aware of the changes to how COVID-19 antivirals, vaccines, and over-the-counter test kits will be covered. Employers must decide if they will continue to cover over-the-counter test kits. At RxBenefits, we’ve opted our clients out of covering OTC test kits — keeping in line with traditional coverage for items purchased without a prescription.
Plan sponsors likely will be glad to hear that expanded access to telehealth is expected to continue, and pharmacists’ ability to prescribe anti-viral medications to COVID-19 patients will continue if plan sponsors elected to enroll in the program.
How will the end of the emergency measures impact plan spend?
The supply of federal government-purchased supply of antivirals and vaccines is anticipated to last until late fall of 2023 — delaying any plan cost for these products. Once the supply is depleted, plan sponsors will be responsible for the cost of the antivirals and vaccines. As the emergency declarations ended, the Centers for Medicare and Medicaid Services and the U.S. Department of Health and Human Services provided multiple fact sheets and FAQs.
Employers must cover the COVID-19 vaccines as preventative care at a zero-dollar copay for members under the Affordable Care Act unless the plan has grandfathered status. This means the total cost of the vaccine will go to the plan, and the price tag of the vaccines is expected to rise as manufacturers prepare for the private-market release. On average, the government paid $30 per dose for the COVID-19 vaccine, and the same shot is expected to cost plan sponsors between $110 and $130 a dose.
Inform your clients that the COVID-19 vaccination rates have tapered, with 68% of the population fully vaccinated and 34% having received an additional booster shot, according to the Centers for Disease Control and Prevention. Continued utilization of the COVID-19 vaccine and boosters is anticipated to align with the annual flu shot. Once these vaccines have a price tag, plans can calculate the potential incoming costs.
PBM formulary coverage of anti-viral medications is expected to remain after the government supply of anti-viral treatments runs out, but plan sponsors will not be required to cover the full cost of the anti-viral medications. Members should expect traditional out-of-pocket expenses for the treatments. Paxlovid, the brand name for the antiviral used to treat COVID-19, costs the government $535 for a course of treatment.
What can we learn from the pandemic?
From the pandemic came strong public health measures we should continue to carry forward. Our increased focus on proper hygiene and avoiding public places when we’re sick decreased transmission of the common cold and other diseases caused by viruses. These good hygiene and good health skills are essential to continue.
We also learned the importance of clear, consistent communication during the pandemic, and benefit advisors should keep the lines of communication open with plan sponsors moving forward. Talk to your clients about the expected impacts of the end of this emergency measure, and continue to check in with your pharmacy benefits provider to stay up –to date throughout the transition.