Vaccination coverage among U.S. adults is low and well below the Healthy People 2020 Targets, despite the widespread availability of safe and effective vaccines and the long-standing recommendations by the Centers for Disease Control (CDC) and the Advisory Committee on Immunization Practices (ACIP).1,2 The 2010 Affordable Care Act (ACA) eliminated some coverage and financial barriers to adult vaccinations offered by private health insurance and Medicaid, but did not substantially change vaccine coverage or cost-sharing for Medicare beneficiaries enrolled in Medicare Part D.3,4

Medicare Part D plans are required to cover all commercially available vaccines not covered under Medicare Part B that are reasonable and necessary to prevent illness, but cost-sharing is permitted.5,6 Despite Centers for Medicare and Medicaid Services’ (CMS's) encouragement to provide vaccines without cost-sharing, few Part D plans provided vaccines without out-of-pocket spending requirements in 2017.7

Medicare Part D plans include Part D prescription drug stand-alone plans (PDPs) for beneficiaries in Original Medicare and Medicare Advantage Part D (MA-PD) plans. A subset of MA-PD plans, starting in 2017, also are participating in the CMS Centers for Medicare and Medicaid Innovation value-based insurance design model initiative (MA-PD VBID), which targets value-based insurance design for seven conditions (diabetes, chronic obstructive pulmonary disease, congestive heart failure, patients with past stroke, hypertension, coronary artery disease, mood disorders).8

Manatt Health Study Reveals Whether Part D Plans Were Encouraging Vaccinations

In 2017, Part D enrollment across all types of Part D plans was approximately 44 million (including employer-sponsored plans) with about 40% in PDPs.9,10 This study focuses on 34.2 million Part D enrollees across MA-PD (including MA-PD VBID) and PD plans. It excludes enrollees from demonstrations, national programs for all-inclusive care for the elderly (PACE) plans, employer group waiver plans (EGWPs) and employer direct contract plans that are excluded from the Part D data file.11

Manatt Health analyzed whether, during calendar year 2017, Part D plans were encouraging beneficiary vaccinations by placing vaccines within one of several possible zero-dollar cost-sharing tier designs or formulary structures. Beginning in 2012, CMS permitted Part D plans to create a “Vaccine Tier” for zero-dollar cost-share to promote vaccine utilization.12 While the inclusion of a dedicated Vaccine Tier or, alternatively, a Select Care/Select Diabetes tier that contains vaccine products as part of a multiple-tier formulary structure is not a requirement, sponsors who choose to offer one of these formulary structures must set the cost-sharing at zero dollars.13 Plans may also offer other tiers with zero-dollar cost-share, such as preferred drug tiers.

Manatt examined ten vaccines recommended by ACIP and the CDC for adults older than 65 years or for adults with certain risk factors. The vaccines are used to prevent various diseases such as tetanus, diphtheria, and pertussis, herpes zoster (shingles), hepatitis A and B, chicken pox, and meningococcal disease, including Boostrix®, Zostavax®, Varivax®, Menomune®, Havrix®, Vaqta®, Engerix-B®, Recombivax HB®, Twinrix® and Tenivac.14 Our findings show that:

  • In CY 2017, few Part D plans of any type (MA-PD, MA-PD VBID, PDP) designate a dedicated Vaccine Tier with zero-dollar cost-share. No MA-PD VBID or PDP plans have a dedicated Vaccine Tier. In MA-PD plans (including MA-PD VBID), only 6%–7% of enrollees have access to a zero-dollar cost-share dedicated Vaccine Tier. (See Figure 1.)
  • Slightly more but still few Part D plans of any type (MA-PD, MA-PD VBID, PDP) offer zero-dollar cost-sharing for vaccines regardless of tier label (e.g., Vaccine Tier, Select Care Tier, preferred brand tier). No MA-PD VBID or PDP plans offer zero-dollar cost-sharing regardless of tier label. In MA-PD plans (including MA-PD VBID), about 9%–10% of enrollees have access to zero-dollar cost-share regardless of the tier label. (See Figure 1.)
  • In the first year of implementation, MA-PDP VBID plans do not apply value-based insurance design to vaccines. No MA-PDP VBID plans place vaccines in a zero-dollar cost-share tier.
  • Copayments were the primary cost-sharing vehicle for those Part D plans (MA-PD, MA-PD VBID, PDP) that require cost-sharing for vaccines. Depending on the vaccine, 53%–80% of enrollees in either MA-PD or PD plans were responsible for vaccine copayments, while 20%–47% of enrollees were responsible for coinsurance. Enrollee coinsurance responsibility was more frequent for Zostavax® than for the other vaccines surveyed. (See Figure 2.)

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Sources: National Drug Classification (NDC) codes for adult vaccines taken from the Medi-Span database (September 2016); Medicare Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information quarterly public use files (PUFs) for CY 2017 (first quarter of 2017); 2017 Part D Plan Benefit Package (PBP) files. Medicare Advantage (MA)/Part D Contract and Enrollment Data files for January 2017. The Medi-Span database was used to identify all National Drug Classification (NDC) codes associated with the ACIP adult vaccines chosen for this study15 as of September 2016. Formulary coverage for vaccines is based on the Medicare Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information quarterly public use files (PUFs)16 for CY 2017 (first quarter of 2017), in addition to the 2017 Part D Plan Benefit Package (PBP)17 files.18 Enrollment for each plan was obtained from the Medicare Advantage (MA)/Part D Contract and Enrollment Data files for January 2017.19

Notes: Analysis of all MA-PD plan enrollees, including MA-PD VBID plans. No PDP plans had a Dedicated Vaccine Tier. Excludes enrollees from demonstrations, national programs for all-inclusive care for the elderly (PACE) plans, employer group waiver plans (EGWPs) and employer direct contract plans.

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Sources: National Drug Classification (NDC) codes for adult vaccines taken from the Medi-Span database (September 2016); Medicare Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information quarterly public use files (PUFs)1 for CY 2017 (first quarter of 2017); 2017 Part D Plan Benefit Package (PBP)1 files. Medicare Advantage (MA) / Part D Contract and Enrollment Data files for January 2017. The Medi-Span database was used to identify all National Drug Classification (NDC) codes associated with the ACIP adult vaccines chosen for this study20 as of September 2016. Formulary coverage for vaccines is based on the Medicare Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information quarterly public use files (PUFs)21 for CY 2017 (first quarter of 2017), in addition to the 2017 Part D Plan Benefit Package (PBP)22 files.23 Enrollment for each plan was obtained from the Medicare Advantage (MA) / Part D Contract and Enrollment Data files for January 2017.24

Notes: Analysis of all MA-PDP, MA-PDP VBID and PDP enrollees that required cost-sharing. Excludes enrollees from demonstrations, national PACE plans, EGWPs and employer direct contract plans.

Most Part D Plans Continue to Require Out-of-Pocket Costs

Although CMS recommends that Part D plans encourage adult vaccination through zero-dollar cost-sharing, most Part D plans continue to require patients to pay out-of-pocket costs. Notably, plans currently participating in the CMS MA-PD VBID model initiative are also not applying zero-dollar vaccine cost-sharing as a value-based benefit design principle at this time.