Your Paxlovid for COVID should still be free – But there are some changes | KQED

Federal coverage or not, your California health insurance will still cover Paxlovid

We are now six months from the end of the federal public health emergency for 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 maintained far more COVID coverage than people living in other states. Specifically, State Bill 1473 required insurers to continue to cover the costs of therapeutic COVID treatments like Paxlovid, as well as reimburse their members for the costs of up to eight over-the-counter COVID tests one month after the end of the public health emergency.

The California Department of Managed Health Care (DMHC) said health plans regulated by its agency — which includes HMO plans and “some other types of plans” — “must cover COVID-19 tests, vaccines and treatment without the prior authorization of the health plan.” The California law said that the DMHC “also prohibits cost sharing and management of utilization for therapy/Paxlovid, similar to tests and vaccines”.

Coverage: Your health insurer cannot deny you coverage for Paxlovid. But what did he say…

If you have health insurance, be sure to apply for Paxlovid “in-network” to be covered starting November 12th.

This California law also required insurers to cover these costs regardless of whether a patient sought “in-network” COVID services. But it will only keep the current situation in place until six months after the end of the federal emergency – a period that ends on November 11.

Previously, Paxlovid supplies were funded by the federal government and were free, regardless of health insurance status – so the concept of getting your Paxlovid “in-network” did not apply. But as California reaches that mark of “six months after the end of the federal emergency”, it means that starting on November 12, insurers can ask their members to get some care and “in-network” COVID treatment. And, confirms DMHC, “after November 11, if [patients] access services from an out-of-network provider, they may be charged a cost-sharing fee, such as a co-payment or co-insurance.

DMHC insists that “if health plan members access these services from a provider in their health plan’s network, they do not need to pay anything for these services.” Going out of network after November 12 could look like getting a telehealth visit with a provider that isn’t in your health plan’s network or using an out-of-network pharmacy for your Paxlovid prescription, if your plan requires you to use only certain pharmacies.

“It’s hard to give general advice because it really depends on the plan,” said Wright of Health Access, but “in general,” he insists that people should now seek their COVID treatment, or their COVID vaccine, “so that they would normally have other health care through their plan.”

“As long as you get care the way you typically get other care, including other prescriptions … then you should be fine,” Wright said. “You can double check with your plan if you’re worried.”

What if you believe you’ve been wrongly charged for the cost of Paxlovid — or a COVID test or vaccine, for that matter? DMHC said if you have a bill you don’t believe you should pay, such as a “qualifying” treatment, you should “contact us first.” [your] health plan to file a complaint, sometimes called an appeal, and include a copy of the bill.

If you “don’t agree” with your health plan’s response to your complaint, or “if the plan is taking more than 30 days to resolve the issue,” DMHC recommends contacting its Help Center at line or by calling 1-888-466-2219. .

Your health plan should also not claim to get to go out of network to get COVID care, Wright said.

“If your plan does not provide you with access to any of these therapies or tests or treatments, then you are violating the consumer protections of what you are entitled to as a member of the plan,” he said.

“Yes, it will have to be on the net, but [plans] they are required to provide that care in the network in a timely manner,” he emphasized. “And if they do not, that you have the right to complain [to DMHC] and take this care.”

“You don’t have to go off the grid and deal with a big bill,” he added.

The takeaway: If you have health insurance, be sure to go online to apply and take Paxlovid after November 12.

If you don’t have insurance, Paxlovid will always be free

If you do not have health insurance and have wanted Paxlovid for the past few years, the California Department of Health (CDPH) recommends using Sesame Care, California’s COVID telehealth service.

This program is intended to “support uninsured and underinsured individuals in the State of California who cannot connect with a health care provider within 24 hours of receiving a positive test result,” CDPH said. People without insurance should visit to make a free phone or video appointment through Sesame Care or call (833) 686-5051 (6 a.m. to 4 p.m. PT, seven days a week). When you speak to a provider through Sesame Care, they will prescribe Paxlovid if you are eligible, and it will be mailed to you or available at a nearby pharmacy.

This Sesame Care consultation and Paxlovid prescription should be free. Sesame Care’s website said that if you are asked to pay for any of these services, you should call Sesame Care at (888) 897-1244 so they “can follow up with the pharmacy.” CDPH confirms that this service “will continue to provide free appointments until February 2024”. (Be sure to only use Sesame Care’s free Sesame Care website at and not to click on other parts of the Sesame Care website. Sesame warns that if you enter the regular Sesame Care website, You will be charged for their services.)

In the long term, the Department of Health and Human Services (HHS) said Paxlovid costs for the uninsured and underserved will be covered by a separate federal program until 2028.

If you to get Health insurance, you can also use Sesame Care for a free telemedicine appointment if you have not been able to connect with your regular doctor within 24 hours of receiving a positive test result, according to CDPH. But keep in mind that the CDPH also said that “the cost of the medication may vary depending on the patient’s insurance status after the marketing of Paxlovid/Lagevrio begins in November.”

Remember, federal stockpiles of these drugs will still be around for a while, and CDPH confirms that “federally purchased COVID-19 medications that are still in supply will remain free for all patients, regardless of insurance status.” But “once the federal supply runs out, the price of the commercial product will depend on the individual’s insurance,” the agency said.

If you have health insurance, be very clear about that detail with the telehealth provider you speak with Sesame Care, and ask if it is possible to find out if there is a Paxlovid prescription that you have to come from that federal reserve free and if you have to anticipate any costs. -share from your insurance to get the prescription through Sesame Care.

The takeaway: Don’t panic about the new commercial sticker price of Paxlovid if you don’t have health insurance—there are still ways to get it for free.

The official eligibility criteria for a Paxlovid prescription have not changed (yet)

Back in December 2021, Paxlovid was the first oral antiviral treatment for COVID authorized by the Food and Drug Administration (FDA). Due to a limited supply, Paxlovid was initially used only to treat patients deemed most at risk of serious illness from COVID – but later in 2022, it was expanded to more pharmacies in the United States as part of a national push to get Paxlovid to more. COVID patients who could benefit from this because of existing health factors.

California also sent a notice to health care providers in December 2022, reminding them of “breadth of supply” and urging them to only refuse to prescribe Paxlovid in “situations in which the risk of prescribing clearly outweighs the benefits of the treatment in the prevention of hospitalization, death. , and the potential to reduce the risk of long-term COVID”.

The state’s most up-to-date guidance for Paxlovid prescriptions comes 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 progression of the disease”. As for what constitutes that “high risk,” NIH follows the CDC’s list of medical conditions that could potentially put a person at higher risk of severe illness, hospitalization, or death from COVID, which includes immunocompromise, disability, mental health conditions including depression, body. mass, physical inactivity and being a current or former smoker.

So will Paxlovid’s move to the commercial market (and the differences in how to access an in-network prescription) change who is eligible to be prescribed the antiviral? When KQED asked CDPH, the agency said they will continue to “review and update the guidance” and pointed to the NIH’s Paxlovid guidance as “the most up-to-date.”

Wright of Health Access said that as the price of Paxlovid increases, insurers may also “be more careful about these guidelines,” but that “it shouldn’t have an impact on people’s pockets. [expenses]even if it provides a cost that we will all bear first.”

Takeaway: If you test positive for COVID, it’s still worth asking your provider if you’re a good candidate for Paxlovid — even if they don’t consider you “high risk.”

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At KQED News, we know that sometimes it can be difficult to follow the answers to navigate life in the Bay Area in 2023. We’ve published clear and practical explainers and guides about COVID, how to cope with the intense winter weather , and how to exercise your right to protest safely.

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