Guide to Vaccine Coverage Policies

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The IRA expanded vaccine access, but variations in federal policies governing vaccine coverage requirements and implementation remain

Over the last decade, federal policymakers have aimed to standardize and expand immunization coverage across markets. Most recently, Congress passed the Inflation Reduction Act, which included two provisions modifying vaccine coverage in Medicaid and Medicare.

  • Eliminating Vaccine Cost-Sharing in Medicare Part D: Effective January 1, 2023, all Medicare Part D plans are required to cover all Advisory Committee on Immunization Practices (ACIP)-recommended adult vaccines not covered under Part B with no cost-sharing, even if the beneficiary is in the deductible phase of the benefit.
  • Mandating Medicaid Coverage of Adult Vaccines: Effective October 1, 2023, all state Medicaid programs are required to cover all ACIP-recommended adult vaccines and their administration without cost-sharing. This new policy aligns coverage for traditional Medicaid with that of the expansion population for whom vaccine coverage was already mandated.

As a result of these policy changes, most individuals in the US now have a pathway to no-cost coverage of all vaccines recommended by ACIP.

While coverage is now required across most markets, variation exists in federal policies governing which immunizations are subject to coverage requirements, the timeline for which coverage requirements must be in effect, and other elements impacting patient access. These variations can limit where and from whom individuals can receive their immunizations. To provide clarity on the vaccine coverage policy landscape, Avalere published a whitepaper summarizing key policies across markets.

While policy landscape evolution expanded the populations for whom coverage without cost-sharing is required, remaining policy variations could create barriers to coverage for certain populations, including under- and uninsured individuals. Going forward, it is likely that policymakers and other stakeholders will consider reforms aimed at populations that continue to encounter access challenges.

To learn more about vaccine coverage policies, connect with us.

Funding for this research was provided by Pfizer. Avalere retained full editorial control.

Download the white paper, “A Guide to Vaccine Coverage Policies.”


Webinar | A Closer Look at Patient Support On June 6 at 2 PM ET, Avalere experts will explore how potential implications of the Inflation Reduction Act (IRA)’s out-of-pocket cap, in addition to other key regulatory and policy activities shaping benefit design and patient cost-share (e.g., EHB), could impact patient commercial and foundation assistance. Learn More
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