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Fewer Seniors Get Vaccinated as Their Out-of-Pocket Costs Increase

Summary

New research shows higher cost sharing for vaccines under Part D leads to fewer seniors getting vaccines. Immunization rates are higher for vaccines covered by Part D plans with lower cost sharing.

New research from Avalere finds that the number of seniors getting the shingles vaccine decreases as seniors’ out-of-pocket costs for the vaccine increase.

Specifically, Avalere experts observed a 40% to 60% higher uptake for the shingles vaccine among enrollees in Part D plans that offered $0 cost sharing from 2012 to 2016. In total, fewer than 10% of Part D enrollees receiving the shingles vaccine were in a plan offering $0 cost sharing, while all other enrollees paid, on average, 40% of the vaccine’s cost out of pocket. In 2016, 95% of Part D beneficiaries faced cost sharing for the shingles vaccine, paying $85 out of pocket on average.

Research has shown that immunization rates for vaccines covered under Medicare Part B are significantly higher than for vaccines covered under Part D. For example, in 2016, 67% of non-institutionalized adults 65 and older received the pneumococcal vaccine, which is covered under Part B, while only 34% of adults 65 and older obtained the shingles (or herpes zoster) vaccine, which is covered under Part D.

Cost-sharing requirements for vaccines vary across markets. Differences in patient cost-sharing obligations partially explain the significant variance in immunization rates across Parts B and D. Congress mandated coverage of the influenza, pneumococcal, and hepatitis B (for intermediate and high-risk populations) under Part B with a prohibition on cost sharing. Under the Medicare Modernization Act (MMA), passed in 2003, all other commercially available vaccines are to be covered under Part D. The MMA does not prohibit Part D plan sponsors from requiring patient cost sharing for vaccines. Similar to Part B, under the Affordable Care Act, vaccines covered through commercial health coverage are statutorily required to be offered at $0 cost sharing.

Part D beneficiaries encounter substantial cost sharing. A 2016 Avalere report found that beneficiary cost sharing for vaccines covered under Part D in 2015 was between $42 and $54 in Medicare Advantage prescription drug plans (MA-PDs), and between $14 and $102 in stand-alone Part D prescription drug plans (PDPs). Cost sharing has previously been established as a barrier to patient receipt of recommended vaccines. Other factors may also contribute to lower immunization rates under Part D relative to Part B, including physician billing and reimbursement issues.

In the CY 2016, CY 2017, and CY 2019 Advance Notice and Call Letters, which provide sub-regulatory guidance for Part D plan sponsors, the Centers for Medicare & Medicaid Services (CMS) encouraged Part D plans to place vaccines on a $0 cost-sharing tier. Despite this encouragement, the average share of Part D enrollees receiving the shingles vaccine in $0 cost-sharing plans decreased between 2015 and 2016, per Avalere’s findings.

To learn more about Avalere’s work in the vaccines space, connect with us.

Methodology

Avalere analyzed Medicare prescription drug event (PDE) data for 2012-2016 under a CMS research data use agreement. Avalere analyzed a cohort of patients that included all Non-LIS Part D enrollees receiving the shingles vaccine, which represented less than 20% of all beneficiaries. We compared utilization for the shingles vaccine (share of enrollees receiving the shingles vaccine), Zostavax®, and average patient out-of-pocket costs per plan across Part D plans.

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