Richard H. Hughes, IV, Member of the Firm in the Health Care & Life Sciences practice, in the firm’s Washington, DC, office, was quoted in The New York Times, in “New RSV Vaccines Aren’t Covered by Some Health Insurance Plans,” by Dana G. Smith. (Read the full version – subscription required.)

Following is an excerpt:

When the Food and Drug Administration approved two R.S.V. vaccines earlier this year for adults aged 60 and up, they were heralded as a potentially lifesaving breakthrough. Every year, between 6,000 and 10,000 people in the United States over the age of 65 die from R.S.V., and 60,000 to 160,000 are hospitalized because of it. The vaccines, which are manufactured by Pfizer and GSK, are both over 80 percent effective at preventing lower respiratory symptoms, such as cough and shortness of breath, associated with an R.S.V. infection.

But currently, some insurance plans aren’t covering the cost, forcing people to pay hundreds of dollars if they want to be protected. …

Several common vaccines, including those for the flu and Covid-19, are included under Medicare Part B, which provides medical coverage. However, the R.S.V. vaccines, as well as a few others, including the vaccine for shingles, are covered under Medicare Part D, which pays for prescription drugs. As a result, Medicare enrollees without a Part D plan — roughly 16 million people — may have to pay for the R.S.V. vaccine out of pocket depending on their non-Medicare prescription drug coverage.

“This is just the result of poor policymaking,” said Richard Hughes IV, avaccine-law expert at the firm Epstein Becker Green and the former vice president of public policy at Moderna. “I think that vaccines, all vaccines, should be accessible in all settings of care, and so this fragmentation is really just not good.” …

For people with private insurance, like Mr. Dhooge, the situation is less clear. According to the Affordable Care Act, private health insurers must cover the cost of preventive care, including vaccines recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. However, the A.C.I.P. recommendations for the R.S.V. vaccine put the final decision in the hands of individuals in consultation with their doctors: The official guidance says that anyone aged 60 years or older “may receive a single dose of R.S.V. vaccine, using shared clinical decision-making.”

Private health insurers have sometimes used this language as a loophole to get out of paying for vaccines, claiming that shared clinical decision-making doesn’t qualify as an official A.C.I.P. recommendation, Mr. Hughes said.

Related reading:

Seattle Times, “Some Older Adults Are Being Charged Over $300 for the New RSV Vaccine.”

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