Insurance lag results in wait for COVID-19 vaccine

Penelope Higa of Aiea had been waiting for the updated COVID-19 vaccine to become available.

She had been watching developments closely, and being over the age of 65 with travel plans in the near future, she wanted to get it as soon as possible.

Over the weekend, Higa walked into a local Longs Drugs to get it but quickly learned that her insurer, the Hawaii Medical Service Association, did not cover the new COVID-19 vaccine and that the out-of-pocket cost would be close to $200.

When she asked why it was not covered, she was told to call HMSA.

So she decided to wait, and watched as others went in and did the same when told their insurance did not cover the vaccine.

“I was shocked,” she said. “It seems very negligent on the part of HMSA that they would let this lapse like this when people have been waiting for this particular vaccine to come out.”

The updated COVID-19 vaccines target more recent XBB lineages of the omicron variant and are recommended by the Centers for Disease Control and Prevention to prevent potentially serious outcomes this fall and winter as well as to reduce the chances of suffering from long COVID.

They are the first to be rolled out since the federal public health emergency for COVID-19 ended May 11. Thus, they are not being purchased or distributed by the U.S. government, but via the commercial market with coverage by health insurers.

But the transition to the commercial market seems to have come across several hiccups, leaving early vaccine seekers without coverage and numerous questions.

HMSA issued a written response to the Honolulu Star-­Advertiser, saying it is covering the latest COVID-19 vaccines.

“This is the first commercial vaccine product so it is taking us some time to implement the new codes into our system and we are experiencing some technical difficulties, which we expect to have resolved soon,” said Dr. Stefanie Park, HMSA vice president and chief medical officer, in a statement. “We are encouraging our members to get the updated flu and COVID-19 vaccines as they become available in our state and are doing our best to make sure our systems are able to reimburse members for this important medical benefit in alignment with the CDC’s recommendation.”

Park added that if members were required to pay out-of-pocket costs during this brief period, they will be able to seek reimbursement and should inquire with the pharmacy about the process.

HMSA commercial plan members might have a copay, depending on their plan benefits, she said. There should be no copay for Medicare Advantage and QUEST Integration members receiving the COVID-19 vaccine.

A recent call to HMSA’s customer service, however, did not yield specific answers after a half-hour-long wait, with ambiguity over whether there would be reimbursements for out-of-pocket COVID-19 vaccine payments.

HMSA, an independent licensee of the Blue Cross and Blue Shield Association, covers more than half of Hawaii’s population.

On Sept. 11 the U.S. Food and Drug Administration authorized the updated vaccines. On Sept. 12 the Centers for Disease Control and Prevention recommended everyone ages 6 months and up get them.

The vaccines became available following a steady upward trend in U.S. COVID-19 hospitalizations since summer.

The state Department of Health on Thursday recommended residents get the updated COVID-19 vaccines for enhanced protection ahead of the holiday season.

CVS Pharmacy, which operates Longs Drugs in Hawaii, announced it expected all locations to be in stock by early this week.

A search on vaccines.gov found that dozens of CVS Pharmacy locations and a few Walgreens locations on Oahu have the vaccines in stock.

CVS said it was aware of the insurance coverage situation earlier this week.

“Some payers are still updating their systems and may not yet be set up to cover the updated COVID-19 vaccines,” said CVS in an issued statement. “If this happens, our pharmacy teams can help patients schedule an appointment for a later date.”

According to a KFF report, COVID-19 vaccine manufacturers charged the federal government an average of about $20 per dose for vaccines during the earlier years of the pandemic but are asking for five to six times more on the commercial market.

CDC assured the public that most Americans could still get the COVID-19 vaccine for free and that most health insurance plans would cover the costs, as well as Medicaid and Medicare plans. The state Health Department echoed these reassurances Friday at a virtual news conference.

Med-QUEST, Hawaii’s Medicaid program, covers the COVID-19 vaccines and has paused disenrollments statewide for the remainder of the year.

But even folks covered by Med-QUEST were reportedly having problems processing insurance for COVID-19 vaccines at their local Longs Drugs.

On its website, Kaiser Permanente said it expects to begin administering the updated COVID-19 vaccines in most areas by Sept. 28.

“We’re recommending that Kaiser Permanente members receive their updated COVID vaccine at a Kaiser Permanente facility,” said Kaiser in a statement. “The updated COVID-19 vaccines will be covered according to the coverage of routine vaccinations provided by members’ plan benefits when administered at a Kaiser Permanente facility.”

HMAA said on its website that all vaccines recommended by the Advisory Committee on Immunization Practices are covered at 100% via in-network participating providers.

For those who are uninsured or underinsured, CDC has rolled out a Bridge Access Program, providing no-cost COVID-19 vaccines to adults through the end of 2024. Participants include Longs Drugs, Walgreens and the Waianae Coast Comprehensive Health Center.

Jacob Schafer, WCCHC’s director of infection control, said the center has ordered the updated COVID- 19 vaccines and hopes they will be available by the end of this month or in early October.

“For the vast majority of our patients and community members, we will bill their insurance,” he said. “We are hearing most will provide the vaccine at no cost. … We have no reason to think that’s not the case but still waiting to hear confirmation on that.”

Those who are eligible can participate in the federally funded Bridge Access and Vaccines for Children programs.

Higa, a longtime HMSA customer, said she is disappointed at the health insurer’s failure to prepare in advance for the rollout as she has a specific timeline to meet before going on her trip.

“I just expected, OK, it’s available,” said Higa. “It’s approved, it’s covered by my insurance. I didn’t think it was going to be this period of waiting to be approved.”