High-risk Covid-19 patients could see reduced access to Pfizer and Merck’s antiviral pills without a federal mandate that insurers pay pharmacies for dispensing the medications, industry groups and analysts say.
Pharmacy groups argue the Medicare agency should require minimum insurance payments for the tasks involved with distributing the at-home treatments, including conducting risk assessments and educating prescribers. Adequate payment is especially needed for small, independent pharmacies already struggling to meet testing and vaccination demands, but some health plans are doling out as little as $1, they say.
Pharmacists are getting “slapped in the face with really ridiculous payment rates,” said Kurt Proctor, senior vice president of strategic initiatives at the National Community Pharmacists Association. But they’re trying to “do everything they can for their patients,” he said.
Pfizer Inc.’s Paxlovid and Merck & Co.’s molnupiravir, cleared by the FDA in December 2021, offer treatment options for people who test positive for the virus and are at higher risk of hospitalization.
The Centers for Medicare & Medicaid Services said in November guidance that while certain antiviral drugs will initially be available at no cost to pharmacies, typical dispensing fees aren’t automatically covered. The agency said it “strongly encourages” sponsors of Medicare Part D prescription drug plans to pay those fees, but didn’t suggest an amount.
Without guidance on what an appropriate dispensing fee would be, “everybody’s left on their own to just make up a number,” Proctor said.
Health insurance plans are paying as high as $10.50 for the fee—an amount that should be closer to the $40 Medicare requires for coverage of a single dose Covid-19 vaccine, the NCPA, which represents more than 19,000 independent pharmacies across the U.S., said in a Jan. 18 letter to the CMS.
Plan sponsors, however, argue they are complying with the guidance and acting with an interest in keeping patient costs low.
The Pharmaceutical Care Management Association, which represents the pharmacy middlemen that help decide how a drug will be covered by insurance, said in an email that its members are “stepping up to support the government’s efforts” to provide effective Covid-19 treatments and that they are “making voluntary payments to pharmacies in order to maintain appropriate access to the medications for patients.”
A CMS spokesperson said in an email that the agency has encouraged health plans to consider paying pharmacies dispensing fees that may be higher than normal negotiated rates, due to the high demands placed on health-care providers during the pandemic. The spokesperson added that the agency is committed to making sure Americans can easily access any FDA-authorized Covid vaccines and therapies.