Editor’s Note: Vaccination utilization among U.S. adults is low, and well below the Healthy People 2020 targets, despite widespread availability of safe and effective vaccines and long-standing use recommendations by the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP). The 2010 Affordable Care Act (ACA) eliminated some coverage and financial access barriers to adult vaccinations covered by private health insurance and Medicaid, but it did not substantially change vaccine utilization or cost sharing for beneficiaries enrolled in Medicare Part D. The law requires that Medicare Part D plans cover all commercially available vaccines not already covered under Medicare Part B, if the vaccine is reasonable and necessary to prevent illness.
In a new issue brief,1 summarized below, Manatt Health’s analysis shows that despite encouragement by the Centers for Medicare & Medicaid Services (CMS) for Part D plans to provide vaccines without cost sharing to incentivize the use of these preventive services, about 4% or less of Medicare Part D enrollees had access to the vaccines examined in this study with no cost sharing, depending on the vaccine, in either Medicare Advantage Part D Prescription Drug Plans (MA-PDPs) or stand-alone Prescription Drug Plans (PDPs) for CY 2017, with little change since 2015. Importantly, no PDPs offered zero-dollar cost sharing for the vaccines under study between 2015 and 2017. Click here to download the full issue brief and its companion chart pack.
The Focus of the Study
Medicare Part D plans include MA-PDPs and PDPs. PDPs may be purchased by beneficiaries enrolled in traditional Medicare Part A and B programs. In January 2017, Part D enrollment across all types of Part D plans was approximately 42.2 million, with about 59% in PDPs. Enrollment increased from 38.6 million in January 2015 (61% in PDPs).
Beginning in 2012, CMS permitted and encouraged Part D plans to create a “vaccine-only tier” that offers zero-dollar cost sharing to promote vaccine utilization. However, the inclusion of a dedicated vaccine-only tier—or a “Select Care/Select Diabetes” tier that contains vaccine products—as part of a five- or six-tier formulary is not required. Sponsors that choose to offer one of these formulary tiers must set the cost setting at zero dollars. Plans also may offer other tiers with zero-dollar cost sharing, such as preferred drug tiers.
Manatt analyzed whether the Part D plans were encouraging beneficiaries to be vaccinated by placing adult vaccines on tiers with zero-dollar cost sharing during calendar years 2015–2017. For this analysis, a “zero-dollar cost share” tier refers to any tier where cost sharing is zero, regardless of the tier label name.
Manatt’s study focuses on non-low-income subsidy (non-LIS) Part D enrollees in MA-PDPs and PDPs who can face high cost sharing, unlike enrollees eligible for LIS, who, by statute, have reduced cost sharing. The study excludes enrollees from demonstrations, national programs for all-inclusive care for the elderly (PACE) plans, employer group waiver plans (EGWPs), employer direct contract plans, and plans where Medicare has suppressed public use data for various reasons.
The study examines 10 vaccines: tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, adsorbed (Boostrix®); zoster vaccine live (Zostavax®); varicella virus vaccine live (Varivax®); A/C/Y/W-135, meningococcal polysaccharide vaccine, groups A, C, Y and W-135 combined (Menomune®); hepatitis A vaccine (Havrix®); hepatitis A vaccine, inactivated (Vaqta®); hepatitis B vaccine recombinant (Engerix-B®); hepatitis B vaccine recombinant (Recombivax HB®); hepatitis A and hepatitis B recombinant (Twinrix®); and tetanus and diphtheria toxoids vaccine, adsorbed (Tenivac™). The vaccines selected for this study (known as study vaccines) address a broad range of preventable conditions and are recommended by ACIP/CDC for general use for all adults 65 years of age or older, as well as for adults with certain risk factors.
Key Study Findings
Manatt’s analysis revealed some critical facts.
Few non-LIS Part D enrollees had access to vaccines through zero-dollar cost share. Across MA-PDPs and PDPs, about 4% or less of non-LIS Part D enrollees had access to the vaccines examined in this study through zero-dollar cost sharing in 2017, depending on the vaccine. When zero-dollar cost sharing was available, it was usually offered through a dedicated vaccine-only tier. There was little change in access to vaccines through dedicated vaccine-only tiers or other zero-dollar cost-share tiers between 2015 and 2017.
Less than 9% of non-LIS MA-PDP enrollees had access to vaccines through zero-dollar cost share in 2017. Between 8.0% and 8.6% of MA-PDP non-LIS enrollees in 2017 had access to the vaccines examined in this study through zero-dollar cost sharing, depending on the vaccine. Among the MA-PDPs that required coinsurance for the study vaccines in 2017, more than 30% of non-LIS enrollees had a coinsurance rate exceeding 35% for these vaccines. Among MA-PDPs that required copayments in 2017, less than 3% of non-LIS enrollees had copayments less than $26 for these vaccines.
No PDPs offered zero-dollar cost sharing to non-LIS enrollees for these vaccines. Among PDPs that required coinsurance in 2017, coinsurance rates for the study vaccines were rarely less than 11% for non-LIS enrollees, and average coinsurance rates were 35% or greater for nine of the ten vaccines. Among PDPs that required copayments, less than 15% of non-LIS enrollees had copayments under $26 in 2015, declining to less than 9% under $26 in 2017.
Among non-LIS enrollees with cost sharing for these vaccines, MA-PDPs had higher weighted average copayment amounts, but lower weighted average coinsurance rates relative to PDPs. Although only MA-PDPs offered zero-dollar cost sharing for the vaccines studied, PDPs had a lower median estimated out-of-pocket cost for eight of the ten vaccines studied.
Median estimated cost sharing for non-LIS MA-PDP enrollees in 2017 was between $39 and $47 across the vaccines studied. By comparison, median estimated cost sharing for non-LIS PDP enrollees ranged between $27 and $75 depending on the vaccine, a slightly broader range than for MA-PDP enrollees. However, estimated out-of-pocket costs could exceed $100 for either MA-PDP or PDP enrollees for some vaccines.
In 2017, for the study vaccines, average weighted cost sharing at the state level was generally more homogeneous across states in PDPs, compared with MA-PDPs. Among MA-PDPs, the South region typically had the highest cost sharing, with the exception of the District of Columbia and Maryland. Among PDPs, Illinois and Arkansas had the highest out-of-pocket costs for most vaccines.
Despite CMS recommendations since 2012 that Part D plans incentivize the use of adult vaccination by placing vaccines on zero-dollar cost-sharing tiers, most Part D plans (either MA-PDP or PDP-only) continue to require enrollees to pay out-of-pocket costs for vaccines. In 2017, about 4% of Part D enrollees had access to low- or zero-dollar cost sharing, and there has been little change since 2015. For non-LIS enrollees, only some MA-PDPs allowed zero-dollar cost sharing for the vaccines under study.
Most non-LIS enrollees faced a copayment—the most prevalent form of cost sharing for the vaccines under study in both MA-PDPs and PDPs. MA-PDPs had lower weighted average coinsurance rates but higher weighted average copayment amounts for these vaccines relative to PDPs. Non-LIS enrollees in MA-PDPs had slightly higher median estimated out-of-pocket costs compared to enrollees in MA-PDPs for eight of the ten vaccines studied.