Payer Considerations for RSV Vaccine Coverage

EP: 1.Incidence and Prevalence of RSV

EP: 2.Complications Associated with RSV

EP: 3.Populations At Risk for Contracting RSV

EP: 4.Overview of Current Vaccine Landscape

EP: 5.Increasing Awareness of RSV Vaccines

EP: 6.Financial Burden Associated with RSV

EP: 7.Clinical Goals for Treating RSV

EP: 8.Clinical Trials Surrounding Effectiveness of RSV Vaccine

EP: 9.Anticipating Needs of Patients Diagnosed with RSV

EP: 10.Navigating Vaccine Hesitancy

EP: 11.Addressing Barriers Surrounding RSV Vaccines

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EP: 12.Payer Considerations for RSV Vaccine Coverage

EP: 13.Promoting Awareness for RSV Vaccines: Part 1

EP: 14.Promoting Awareness for RSV Vaccines: Part 2

EP: 15.Key Takeaways for Immunizing against RSV

Adam C. Welch, PharmD, MBA, FAPhA: This past RSV [respiratory syncytial virus] season was earlier than it was in years past. What can payers do to activate an earlier coverage for the RSV vaccine in case the season peaks again earlier?

Abby Lynne Singleton, PharmD, BCPS: It’s definitely important for payers to be proactive. I’m very hopeful about a couple of vaccines the FDA should be reviewing within the next month for approval. Sometimes the FDA will approve things early. I’m hoping that might be the cases. We all know how big of a burden RSV plays in our country and in individual health. Hopefully, we can get this ball rolling to make sure patients get access to the vaccines.

Adam C. Welch, PharmD, MBA, FAPhA: To clarify, the FDA is anticipated to act on the RSV vaccine candidates in May 2023 with the ACIP [Advisory Committee on Immunization Practices], looking at the recommendations for these vaccine candidates in June 2023.

Abby Lynne Singleton, PharmD, BCPS: Correct.

Adam C. Welch, PharmD, MBA, FAPhA: How will an ACIP recommendation impact coverage of RSV vaccines?

Abby Lynne Singleton, PharmD, BCPS: ACIP recommendations are invaluable because they get put in the guidelines for all of the United States. They break down the data. They look very closely at the cost and benefit. They make sure that they’re weighing all the risks and benefits for patients to make the most informed decision. Those recommendations are invaluable to payers.

Adam C. Welch, PharmD, MBA, FAPhA: When we talk about payment for the RSV vaccine, we’re thinking about Medicare Part B and Part D as covering vaccines to various extents. When we look at the RSV vaccine moving forward, we have Medicare as a huge payer for this vaccine in the future. Tell me a little more about the payment models of the RSV vaccine as it relates to Medicare.

Abby Lynne Singleton, PharmD, BCPS: Medicare can be very confusing to navigate. Medicare Part B covers flu, pneumonia, and hepatitis B vaccines. Part D typically covers all commercially available vaccines that prevent illnesses, like shingles and the Tdap [tetanus, diphtheria, acellular pertussis] vaccine. That can make it tricky at times for patients. However, I’m optimistic. I’m hoping that they’ll get this rolled out. They’ll get the vaccines out, and Medicare patients will be able to access the vaccines also.

Adam C. Welch, PharmD, MBA, FAPhA: Let’s speculate for a bit. Dr Filer, what are you hearing on the street as far as coverage with these RSV vaccines?

Wanda Filer, MD, MBA, FAAFP: RSV will definitely be on Medicare Part D. I’m a member of a group called the Adult Vaccine Access Coalition [AVAC], and a lot of us are advocating for it to also be covered under Part B. Whether that happens remains to be seen. But the AVAC members are out there. Vaccines save lives and dollars. If Part B and Part D give equal access, patients could get it where they’re comfortable: their medical home, the pharmacy. When it’s Part D only, it can be difficult for some practices. Many physicians don’t even realize they can do Part D. They can, but it’s not easy for many of them. It can be quite cumbersome. That creates a barrier the patients don’t need. I’m advocating for Part B, but I’m not sure if they’re listening. We’re going to hope.

Adam C. Welch, PharmD, MBA, FAPhA: When you talk about having it available in Part B and Part D, we’re also talking about health equity.

Laurene Mascola, MD, MPH: Exactly. You want as many opportunities as possible for patients to get vaccinated, whether that’s in their medical home or in a pharmacy. In some of these socially disadvantaged neighborhoods, there aren’t always pharmacies that are close by or that you feel comfortable going to late at night or on weekends. Perhaps in your medical home with your medical provider you feel more comfortable talking about it. That would be under Part B coverage as opposed to Part D and the pharmacy coverage. To get rid of social disparities, we need to have better access for all.

Wanda Filer, MD, MBA, FAAFP: Here, here.

Marty J. Feltner, PharmD: I agree.

Transcript edited for clarity.