Your Paxlovid for COVID should still be free, but there are some changes KKED

Federal Reserve or Not, Your California Health Insurer Should Still Cover Paxlovid

We are now six months away from the end of the federal public health emergency for COVID, which ended on May 11 and had a major impact on nationwide funding for COVID vaccines and testing. But thanks to laws passed in California during the pandemic, Californians have kept far more COVID coverage than people in other states. Specifically, State Bill 1473 required insurers to continue to cover the cost of therapeutic COVID treatments, such as Paxlovid, as well as reimburse their members for the cost of up to eight over-the-counter COVID tests one month after the end of a public health emergency.

The California Department of Managed Health Care (DMHC) said that health plans regulated by their agency, which include HMO plans and “certain other types of plans,” “must cover COVID-19 tests, vaccines and treatments without prior authorization from the health plan. California law says the DMHC “also prohibits cost-sharing and utilization management for therapeutic/Paxlovid-like testing and vaccines.”

A health insurer cannot deny you coverage for Paxlovid. But that said…

If you have health insurance, be sure to claim Paxlovid “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 out COVID services “in network.” But it maintained the current situation only until six months after the end of the federal state of emergency, a period that ended on November 11.

In the past, supplies of Paxlovid were funded by the federal government and were free regardless of health insurance status, so the concept of getting your Paxlovid “in network” just didn’t apply. But as California reaches the “six months after the end of the federal emergency” mark, that means that starting Nov. 12, insurers can require their members to receive certain COVID care and treatment “in network.” And, confirms the DMHC, “after November 11, if [patients] access services from an out-of-network provider, they may be charged cost-sharing, such as co-pays or co-insurance.”

DMHC emphasizes that “if health plan members access these services from their health plan’s network provider, they will not have to pay anything for these services.” Going out of network after November 12 may be like visiting a telehealth provider who is not in your health plan’s network or using an out-of-network pharmacy for your Paxlovid prescription if your plan only requires you to use certain pharmacies.

“It’s hard to give general advice because it really depends on the plan,” said Health Access’ Wright, but “in general,” he stresses that people should now seek their own COVID treatment or their The COVID vaccine, ‘as they are. usually received other health services 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 might want to double-check your plan if that worries you.”

What if you think you’ve been mistakenly charged for Paxlovid or the cost of a COVID test or vaccine, for that matter? DMHC said if you get a bill you don’t think you should pay for, such as “qualifying” treatment, you “should first contact [your] file a health plan complaint, 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 is taking more than 30 days to resolve the issue,” DMHC recommends contacting their Help Center online or calling 1-888 by phone -466-2219. .

Your health plan shouldn’t require you to either have to go out of network for COVID care, Wright said.

“If your plan doesn’t provide you with access to any of these therapies or tests or treatments, they’re violating the consumer protections you’re entitled to as a plan member,” he said.

“Yes, it should be on the net, but [plans] it is required to provide that in-network care on time,” 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 off the grid and deal with a big bill,” he added.

Health. If you have health insurance, be sure to go online to ask for and get Paxlovid after November 12th.

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

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

This program is designed to “assist uninsured and underinsured individuals in the state of California who are unable to contact a health care provider within 24 hours of receiving a positive test result,” CDPH said. Uninsured people should visit to schedule a toll-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 Paxlovid for you if you’re eligible, and it will either be mailed to you or available at a local pharmacy.

This Sesame Care consultation and Paxlovid prescription should be free. Sesame Care’s website states that if you are asked to pay for any of these services, you must 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 careful to only use Sesame Care’s free COVID care webpage at and not to click on other parts of Sesame Care’s website. Sesame warns that if you access Sesame Care’s regular website , you will be charged for its services. )

In the long term, the Department of Health and Human Services (HHS) said Paxlovid costs for the uninsured and underinsured would 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 contact 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 once Paxlovid/Lagevrio begins commercialization in November.”

Keep in mind that federal supplies of these drugs will be around for some time, and CDPH confirms that “federally purchased COVID-19 drugs that are still being supplied 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 an individual’s insurance,” the agency said.

If you have health insurance, be very clear about those details with the telehealth provider you speak with through Sesame Care, and ask if it’s possible to know if any Paxlovid prescriptions you receive come from that free federal repository. and should you expect any costs? – Share your insurance to get a prescription through Sesame Care.

Don’t panic about the new Paxlovid commercial sticker price 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 limited supply, Paxlovid was initially only used to treat patients who were considered to be most at risk of severe disease from COVID, but later in 2022, it was expanded to more pharmacies in the United States as Paxlovid more part of a nationwide push to deliver Patients with COVID who may benefit from it due to existing health factors.

California even sent an advisory to health care providers in December 2022, reminding them of “oversupply” and urging them to refrain from prescribing Paxlovid only “in situations where the risk of prescribing clearly outweighs the benefits of treatment to avoid hospitalization and death.” and the potential to reduce long-term COVID risk.”

The state’s most recent guidance for Paxlovid prescriptions comes from the National Institutes of Health (NIH), which states that the drug is recommended for people with “mild to moderate COVID-19” who are at high risk of disease progression. As for that “high risk,” NIH follows the CDC’s list of medical conditions that could put a person at risk of potentially serious illness, hospitalization, or death from COVID, which includes immunodeficiency, disability, mental health conditions , including depression, body. mass, physical inactivity and current or former smoking.

Will Paxlovid’s move to the commercial market (and differences in access to in-network prescriptions) change who is eligible to prescribe the antiviral drug? 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.”

Health Access’s Wright said that as the price of Paxlovid goes up, insurers may also be “more mindful of those guidelines,” but that “it shouldn’t affect people’s pockets. [expenses]even if it provides a cost that we will all bear the premiums.”

Problem: If you test positive for COVID, it’s still worth asking your provider if you’re a good candidate for Paxlovid, even if you’re not considered “high risk.”

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