National issues with COVID vaccine rollout: overview, actions, and next steps

September 23, 2023

Impact: All lines of business

Last week, the Centers for Disease Control (CDC) approved the use of new COVID-19 vaccines and very quickly deployed these products to the marketplace. The quick deployment without advance notice to payers created a disconnect in the timing of when supply was available at some pharmacies and when claims processing systems were updated with new and corrected information, resulting in disruption across the nation.

This caused various member impacts, including rejected claims and vaccine supply issues at pharmacies.

Claims were rejected for a variety of reasons:

  • Initially, claims were rejected due to timing constraints of the healthcare industry updating adjudication systems with new information. According to the Department of Health and Human Services (HHS), these issues were mostly mitigated earlier this week across the industry, with the exception of a few organizations still in the process of making updates.
  • Plans may have elected to not cover the new vaccines through their prescription coverage.
  • Members attempted to process vaccines at pharmacies that do not participate in the plans network.

Prime/Magellan Rx, along with other pharmacy benefit managers (PBMs), met with HHS this week in a collaborative effort to address this national issue. HHS will continue its sessions and has indicated they are also meeting with other sectors of the healthcare industry.

Prime/Magellan Rx Actions
Prime/Magellan Rx took quick action to respond to this event:

  • Systems were updated with new vaccine information, including updating benefit/formulary designs based on client decisions.
  • Daily monitoring of claims with pharmacy outreach as needed
  • Engaging with HHS to partner across the industry.
  • A daily command center has been established to ensure Prime/Magellan Rx continues to have high focus on this event.
  • Customer service scripts are being updated to help advise members, pharmacies and physicians.

Next steps for clients
HHS has stated that clients should be categorizing these vaccines as preventative health with no cost share.

Accordingly, we recommend that clients review their prescription and medical coverage elections for these vaccines based on HHS’s guidance. If any changes to your plans are needed, Prime/Magellan Rx will partner with you to make those changes as expeditiously as possible.

If you have questions, please reach out to your Prime/Magellan Rx client account team representative.