Update on COVID-19 Vaccines and Coverage

December 16, 2020

You’ve undoubtedly read the recent news coverage of the widely reported success of several COVID-19 vaccines.

It’s been widely reported that two companies – Pfizer and Moderna – have reported positive preliminary results from large trial testing of COVID-19 vaccines. Pfizer received Emergency Use Authorization (EUA) from the Food and Drug Administration (FDA) to begin vaccinating the public. Moderna has applied to the FDA for EUA to begin vaccinating the public.

Federal and state health officials will be working with the medical community on the rollout plan for the COVID-19 vaccine. Members should talk to their health care providers about when a vaccine will be available and any questions they might have about the vaccine.

Broad distribution of a coronavirus vaccine is considered months away at this time.

What you need to know

We will share more information as we receive updates about broader vaccine distribution and access. Initially, we anticipate that the cost of the vaccine will be paid by the government.

Blue Cross and Blue Shield of Texas, or plan sponsor (ASO groups), will cover administration of the vaccine as noted below:

Fully insured groups and retail members:

• Must cover the COVID-19 vaccine and its administration as a preventive service with no cost-share to members at in-network providers.
• Must cover at no cost-share to members the vaccine and administration if delivered at out-of-network providers through the end of the public health emergency.

Self-insured (ASO) groups:

• Non-grandfathered self-insured groups must cover the COVID-19 vaccine and its administration as a preventive service with no cost-share to members at in-network providers.
• Non-grandfathered self-insured groups must also cover at no cost-share to members the vaccine and administration if delivered at out-of-network providers through the end of the public health emergency.
• Non-grandfathered self-insured groups that don’t cover preventive vaccines through the pharmacy benefit must cover the vaccine through the medical benefit.
• Grandfathered plans are not required to cover preventive services, including the COVID-19 vaccine. Self-insured employers that have grandfathered plans have the choice to cover the COVID-19 vaccine. If you have a client with a grandfathered self-insured plan, we will be in contact about the option these plans have to cover the vaccine.

Medicare members:

• No cost-sharing on vaccines from in- and out-of-network providers through Dec. 31, 2021. The federal government has stated it will be paying for the cost of the vaccine.

In-network providers will be reimbursed for the administration fee based on contracted rates. Out-of-network (OON) providers will be reimbursed based on established OON reimbursement policy, which follows Medicare rates. We understand that the Pfizer and Moderna vaccines will require two doses.

What you can do

There have been significant decreases in routine immunizations during the public health emergency. Please remind your clients to get all recommended immunizations and vaccines, including their flu vaccine, if they haven’t already.

Also continue to follow Centers for Disease Control and Prevention (CDC) guidelines, including:

• Wash your hands often
• Keep social distance
• Wear a mask or face covering
• Cover your nose and mouth when around others
• Covering your mouth and nose with a tissue when you cough or sneeze into your elbow if one isn’t available
• Clean and disinfect daily
• Monitor your health daily

We continue to monitor information provided by the CDC and other government and health officials. We’ll provide updates when we have them. For the latest information on COVID-19, we recommend visiting the CDC’s COVID-19 website.