Sep 22, 2023

Insurers are supposed to pay for the updated coronavirus vaccine after the federal government stopped buying them. But some consumers are being turned away. By Fenit Nirappil and Lena H. Sun Washington Post September 22, 2023 — 4:17pm Gift Email Copy link Federal officials promised the new COVID shot would be free and covered by insurance, but some Americans have encountered a different reality this week as they tried to get vaccinated, only to be denied coverage or charged up to $200. They have faced myriad complications, from pharmacies being out of network, to the vaccine not showing up on lists of approved medical expenses, to needing prior authorization. Some Americans paid out of pocket to avoid waiting. Others say they weren't even given that option. The hiccups reflect a new reality for COVID vaccines as they go from being treated as a public good to a commercial product. Now that the federal government is no longer buying and distributing all the shots, Americans must endure the usual headaches of dealing with insurance companies and a for-profit health care system. "Last year there was one player — the federal government," Mandy Cohen, director of the Centers for Disease Control and Prevention, said in an interview. "And now there's a lot more players and ... they're not accountable to us." Cohen said most issues should be resolved within days, but that's little comfort to Americans trying to get vaccinated as soon as possible. Eric Allix Rogers forked over the $155.99 for the updated vaccine even though his Chicago pharmacy called ahead of his Monday appointment offering to reschedule because an insurance check showed the shot wasn't covered by his Blue Cross Blue Shield of Illinois HMO plan. He had a bad case of COVID in 2021 before he could get vaccinated and does not want to risk another infection when he travels to Minneapolis next week for a large work event. "We are being told we have to transition to treating COVID as a routine matter, and yet the people responsible for medical care have not figured out how to treat it as a routine matter," said Rogers, 38. "This shouldn't have been complicated." A spokesman for Rogers's insurer said members can get free vaccines at in-network pharmacies and can call customer service if they face challenges. It's not clear how many people like Rogers have encountered trouble getting vaccinated, but social media outlets are flush with similar stories, and federal officials, insurers and pharmacy chains have acknowledged these are not isolated incidents. In a July letter, Chiquita Brooks-LaSure, administrator of the Centers for Medicare & Medicaid Services, told public and private insurers to make sure their systems are prepared to immediately cover the costs of COVID vaccines in the fall. After hearing reports of unexpected insurance denials, CMS has been working with plans to ensure their systems are up to date and is reminding them they must immediately cover authorized COVID vaccines without cost sharing, according to a statement provided by Health and Human Services spokeswoman Ilse Zuniga. "The Biden Administration will continue working to ensure COVID-19 vaccines are widely available to the American public at no-cost to them from their local provider, community health center or pharmacy," the statement said. Federal officials and health experts say some of these insurance problems appear to be a result of insurance systems that have yet to be updated and billing code errors should be resolved in the coming weeks. "We are working closely with the federal government, pharmacies, and other partners to quickly ensure patient access to COVID-19 vaccines with $0 cost sharing and address any issues relating to newly added billing codes quickly," James Swann, a spokesman for the industry group America's Health Insurance Plans, wrote in an email. Separate from insurance troubles, there have also been reports of Americans struggling to find places offering the new vaccines or having their appointments canceled. Administration officials said manufacturers and distributors are working to resolve logistical issues that have caused some delays and that there is no vaccine shortage. Anne Zink, chief medical officer for the Alaska Department of Health, said her vaccine team has been extremely frustrated in their search for updated shots. "Our team is unaware of any vaccine in the state and has been calling pharmacies one by one to see if we can find any," she wrote in a text message. Overall demand for the new vaccine is expected to be low after only 17 percent of eligible Americans received the bivalent booster authorized a year ago. But providers expect an initial burst of demand for the new vaccine from people who care most about protecting themselves against the virus. COVID hospitalizations have been rising since July and the new vaccine targets the latest variants in circulation. Data shows protection against hospitalization from the previous vaccine wanes after four months, particularly for seniors and the immunocompromised. Leesa Weiss said a pharmacist at a Maryland CVS apologetically told her he would have to charge almost $200 for an updated COVID vaccine because her Medicare plan did not accept the billing code for a pre-filled Pfizer syringe. Weiss hoped to get the shot during that Monday appointment because it is two weeks ahead of a planned trip to Europe — and it takes two weeks for COVID vaccines to confer maximum protection. CMS says syringes should be provided at no cost. "It may be this is a hiccup," said Weiss, 67. "I'm hoping I can get the shot before I go abroad and if not, I'll keep my fingers crossed." One common issue that won't be resolved, however, is Americans can no longer expect to get a vaccine wherever they want, because insurers are not required to pay for vaccines administered at out-of-network pharmacies and locations. "Under the national program, anyone could go anywhere regardless of their insurance status," said Kelly Moore, chief executive of Immunize.org, which educates health care professionals about vaccines. "We are still giving everyone the same chance at vaccination at no cost, however, it is more limited than it used to be." Moore experienced the challenges herself when she couldn't get vaccinated at her usual pharmacy because of shipping delays, and then was told she'd have to pay $200 at CVS because it was not in her insurance network. It took her a few hours and a few frustrating phone calls to resolve her situation and eventually get vaccinated at Walgreens, but she worries less-savvy consumers will give up when they encounter hurdles. Ximena Levander and Phillip Kast, a couple in Portland, Ore., wanted to shore up their immunity ahead of a wedding next week, especially because they have a 3-month-old daughter who is too young to be vaccinated. But the pharmacies in their insurance network did not have the new COVID vaccine and their local Walgreens store would not let them pay the full cost. They said the staff at Walgreens provided conflicting reasons for why they couldn't take payment, at various points blaming the vaccine manufacturer, the government and corporate policy. "They said Walgreens wants your money and if we could find a way to bill you, we would," said Levander, 39, a physician. Stephanie Corcilius, a spokeswoman for Walgreens, said that out-of-network patients should be allowed to pay out of pocket and the company would follow up with that store. "Walgreens pharmacists are aware of the procedures to process insurance claims and can assist those who have questions," Corcilius wrote in an email. "We encourage everyone to bring insurance information to their appointment if available but will not turn away those whose insurance does not cover it." After the Washington Post's inquiry, the couple got a call back from Walgreens and were able to pay cash to get vaccinated Thursday. Kast, 41, said the challenges they faced stood in stark contrast to his time volunteering at a mass vaccination site at Portland's convention center staffed by hundreds of National Guard members and other volunteers. "I vividly remember this incredible sense of urgency," Kast said. "It is surprising two and a half years later to see that flip around to, 'Ah, well, no big deal we don't have things figured out for the first few days.'" Customers at some Publix pharmacies in the Atlanta area were told they need prior authorization to get COVID vaccines if they had Humana or United Healthcare insurance plans, according to a pharmacist who was not authorized to speak publicly. A spokeswoman for United Healthcare said it was not requiring prior authorization; spokespeople for Publix and Humana did not address the situation. Zachary Levenson ran into trouble getting vaccinated in Miami when the pharmacy could not verify his insurance information. Then he called the hotline for his insurer, Florida Blue, and a customer service agent told him the vaccine wasn't covered. The pharmacist instead steered him to get his vaccine free by signing up for a program meant to provide free vaccines for people without health insurance, saying that's how he has been bypassing denials for people with health insurance. "What kind of country that's circling the drain am I living in where after years of this public health emergency I can't get something as basic as a vaccine in one of the larger cities in the country?" said Levenson, 40, a sociology professor. In a statement to the Post, Florida Blue confirmed members may have experienced issues as its systems were updated to include the new COVID vaccine, but said pharmacies and beneficiaries can be reimbursed for costs. Vaccine advocates say Americans shouldn't give up if they're charged for the updated COVID vaccine. "I do think this is going to pan out in the next couple of weeks," said Amy Pisani, executive director of Vaccinate Your Family, a vaccine advocacy organization. "We are working out the kinks nationwide and I really hope people circle their calendar and say, I'm going to come back in two weeks." Sun reported from Atlanta.