Federal supplies or not, your California health insurance must still cover Paklovid
We are now six months away from the end of the federal public health emergency due to COVID, which ended on May 11 and had major effects on national funding for COVID vaccines and testing. But thanks to laws passed in California during the pandemic, Californians have retained far more Covid coverage than people living in other states. Specifically, State Bill 1473 required insurers to continue to cover the cost of therapeutic COVID treatments such as Paklovid, as well as reimburse their members for up to eight over-the-counter COVID tests one month after the end of a public health emergency.
California’s Department of Managed Health Care (DMHC) said health plans regulated by its agency — which includes HMO plans and “certain other types of plans” — “must cover COVID-19 tests, vaccines and treatment without prior health plan approval.” ” California law says DMHC “also prohibits cost-sharing and management of the use of therapeutics/paxloids, similar to testing and vaccines.”
Bottom line: Your health insurance cannot deny you Paklovid coverage. But that said…
If you have health insurance, be sure to request Paklovid “in-network” to have it covered starting November 12th
That California law also forced insurers to cover these costs regardless of whether the patient sought “in-network” COVID services. But he only maintained the current situation until six months after the end of the federal emergency – a period that ended on November 11.
Previously, supplies of Paklovid were funded by the federal government and were free regardless of health insurance status — so the concept of getting Paklovid “in network” just didn’t apply. But as California reaches that “six months after the end of the federal emergency” mark, it means that starting Nov. 12, insurers can require their members to get certain “in-network” COVID care and treatment. And, confirms the DMHC, “after November 11, if [patients] access services from out-of-network providers, they may be charged cost-sharing, such as co-payments or co-insurance.”
DMHC emphasizes that “if health plan members access these services from providers in their health plan’s network, they will not have to pay anything for these services.” Going out of network after Nov. 12 could look like a telehealth visit to an out-of-network provider your health plan or using an out-of-network pharmacy for a Paklovid prescription, if your plan requires you to use only certain pharmacies.
“It’s hard to give blanket advice because it really depends on plan by plan,” said Health Access’s Wright, but “in general,” he stresses that people should now seek their Covid treatment, or their COVID vaccine, “at the way they usually get other health care through their plan.”
“As long as you’re getting care the way you normally get other care, including other prescriptions … then you should be fine,” Wright said. “You can double-check your plan if you’re worried about that.”
What if you believe you were incorrectly billed for Paklovid — or the COVID test or vaccine, for that matter? DMHC said that if you receive a bill you don’t believe you should be paying, such as for “qualified” treatment, “you should first contact [your] health plan to file a grievance, sometimes called an appeal, and include a copy of the bill.”
If you “disagree” with your health plan’s response to your complaint or “if the plan takes more than 30 days to resolve the issue,” DMHC advises contacting their online help center or calling them at 1-888-466- 2219.
Your health plan shouldn’t ask you either have to go offline to get COVID care, Wright said.
“If your plan doesn’t give you access to any of these therapies or tests or treatments, then they’re violating the consumer protections you’re entitled to as a plan member,” he said.
“Yes, it will have to be in the net, but [plans] they are obliged to provide that care in the network in a timely manner,” he emphasized. “And if they don’t, you have the right to complain.” [to DMHC] and get that care.”
“You don’t have to go offline and deal with a big bill,” he added.
Takeaway: If you have health insurance, be sure to go online to request and pick up Paklovid after November 12th.
If you don’t have insurance, Paklovid will still be free
If you don’t have health insurance and have wanted Paklovid for the past few years, the California Department of Health (CDPH) advises using Sesame Care, California’s COVID telehealth service.
This program is intended “to support uninsured and underinsured individuals in the state of California who are unable to connect with a health care provider within 24 hours of receiving a positive test result,” CDPH said. Uninsured people should visit sesamecare.com/covid to schedule a free phone or video appointment with Sesame Care or call (833) 686-5051 (6 a.m. to 4 p.m. PT, seven days a week). When you talk to a provider through Sesame Care, they’ll prescribe Paklovid if you’re eligible, and it will either be mailed to you or available at a local pharmacy.
This Sesame Care consultation and Paklovid prescription should be free. Sesame Care’s website states that if you are required to pay for any of these services, you should call Sesame Care at (888) 897-1244 so they “can contact the pharmacy.” CDPH confirms that this service will “continue to provide free appointments through February 2024. (Be careful to use only the free Sesame Care website for COVID care at sesamecare.com/covid and do not click on other parts of the Sesame Care website. Sesame warns that if you go to the regular Sesame Care website, you will be charged for its services. )
In the long term, the Department of Health and Human Services (HHS) announced that Paklovid costs for the uninsured and underinsured will be covered through a separate federal program through 2028.
if you have health insurance, you can also use Sesame Care for a free telehealth appointment if you haven’t been able to connect with your regular health care provider within 24 hours of receiving a positive test result, according to CDPH. But note that CDPH also said that “drug costs may vary depending on a patient’s insurance status after commercialization of Paclovid/Lagevrio begins in November.
Remember, federal supplies of these drugs will continue to exist for some time, and CDPH confirms that “federally purchased COVID-19 drugs that are still available will remain free for all patients regardless of insurance status.” But “once the federal supply runs out, the cost of the commercial product will depend on the individual’s insurance,” the agency said.
If you have health insurance, be clear about those details with the telehealth provider you talk to through Sesame Care and ask if it’s possible to know if any Paklovid prescriptions you get come from that free federal supply and if you should anticipate any cost-sharing from your insurance to get a prescription through Sesame Care.
The bottom line: Don’t panic about the new commercial sticker price of Paklovid if you don’t have health insurance — there are still ways to get it for free.
The official eligibility criteria for a Paklovid prescription have not changed (yet)
Back in December 2021, Paclovid was the first oral antiviral treatment for COVID approved by the Food and Drug Administration (FDA). Due to limited supply, Paclovid was initially only used to treat patients thought to be most at risk of severe illness from COVID — but later in 2022, it was expanded to more pharmacies across the United States as part of a nationwide effort to increase Paclovid patients. with COVID who could benefit from it because of pre-existing health factors.
California even sent an advisory to health care providers in December 2022, reminding them of the “ample supply” and urging them to only refuse to prescribe Paclovid in “situations where the risk of prescribing clearly outweighs the benefits of treatment in preventing hospitalization, death, and the potential for risk reduction.” from long covid.”
The most recent state prescription guidelines for Paclovid come from the National Institutes of Health (NIH), which notes that the drug is recommended for people with “mild to moderate COVID-19 who are at high risk of disease progression.” As for what constitutes that “high risk,” the NIH follows the CDC’s list of medical conditions that could potentially put a person at greater risk of severe illness, hospitalization, or death from COVID, which include immunocompromise, disability, mental health conditions, health conditions including depression, body mass, physical inactivity, and current or former smoking.
So will Paclovid’s move to the commercial market (and the differences in how you access a prescription online) change who can be prescribed the antiviral? When KKED asked CDPH, the agency said it would continue to “review and update the guidelines” and pointed to NIH’s Paxlovid guidelines as “the most up-to-date.”
Health Access’s Wright said that as the price of Paclovid rises, insurers may also “be more careful about those guidelines” but that “it shouldn’t affect people’s personal pocketbook [expenses]even if it comes at a cost we will all bear with the premiums.”
Bottom line: If you test positive for COVID, it’s still worth asking your provider if you’re a good candidate for Paklovid — even if you don’t consider yourself “high risk.”
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