SummaryAn Avalere analysis finds that Medicare Part D plans allow $0 cost-sharing for select vaccines just 4% of the time, likely affecting immunization uptake.
Immunization uptake remains low among US adults and well below the Healthy People 2020 targets. In particular, cost-sharing obligations can create uptake barriers for vaccines, depending on the source of coverage. Specifically, the Affordable Care Act prohibits cost sharing for vaccines in the commercial and Medicaid expansion markets. In Medicare, Part B covers certain vaccines without cost-sharing, while Part D plans may require cost sharing for other vaccines.
This analysis finds that 2020 Medicare Part D plans require a copayment for recommended vaccines 87% of the time. The research also finds that these Part D plans have an average vaccine copayment of $47, though the maximum copayment is as high as $100.
Cost sharing has previously been established as a barrier to patient receipt of recommended vaccines. A previous Avalere analysis found that higher cost sharing for vaccines under Part D correlates with fewer beneficiaries getting vaccines, while lower cost sharing correlates with higher immunization rates for vaccines covered under Part D. That analysis found that 95% of beneficiaries paid higher than $0 cost sharing for the shingles vaccine in 2016, and that beneficiary uptake was 40–60% higher with $0 versus any cost sharing between 2012 and 2016.
Other factors may also contribute to lower immunization rates under Part D relative to Part B, including physician billing and reimbursement issues, physicians administering vaccines not being recognized as providers under Part D, and storage and inventory management burdens for immunizing providers.
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This analysis was conducted using October 2019 data obtained directly from the Centers for Medicare and Medicaid Services (CMS) on Medicare Part D plan features and formulary designs and represents 2020 formulary data. Avalere has been collecting these data since the beginning of the Part D program in 2006 and receives monthly updates, allowing for longitudinal studies and accounting for new product launches. Avalere supplements the formulary data with plan-level enrollment data. The data are updated on a monthly basis and are split between LIS and non-LIS populations. Avalere utilized CMS’s standardized tier names used by Part D plans, including brand, generic, preferred generic, preferred brand, non-preferred brand, injectable, select care, and vaccines. The unit in the figures above represents the share of included vaccines and Part D plan combinations that are listed at a certain tier level or that require a certain type of cost sharing. The denominator is the product of the number of vaccines times the number of Part D plans on the market. Avalere refers to this measure of frequency in the text as the “% of the time.” This analysis does not consider market dynamics other than those stated in the above analysis, such as manufacturer supply, patient demand, or other pertinent factor influencing vaccine uptake. The analysis also excludes cost, Medicare Advantage Medicare-Medicaid plans, Special Needs Plans, and Programs of All-Inclusive Care for the Elderly plans.
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