Thursday, November 18, 2021

Governor Beshear Authorized the 3rd/Booster Shot for ALL Adults in Kentucky, Effective Immediately, BUT ...


... here's the thing - the FDA has not yet officially approved the booster for all adults yet, just select groups -  so "all adults" aren't officially on the labeled indication or "on label"  - just 65 and older, 50+ with health conditions, and residing in a long-term facility.


So because of what I do for a living, here's my concern - insurance companies do not authorize payment of pharmaceuticals that are not "on label" - meaning according to FDA-approved labeled indications and/or CDC guidance.

Although private insurance is not ultimately paying for the vaccines, at present, they are initially billed through your insurance and then file the claims with the government for reimbursement.

So if we get the booster before FDA approval, what happens with billing?

Are our insurance companies going to reject those claims because they're "off'-label" and there's no billing code?

And if they reject coverage, then who pays for it, because the government will never receive the claim from your insurance company to reimburse them?

Definitely don't want to get stuck with a bill for the booster, they're not cheap.

Also, Walgreen's has just told me that their corporate office hasn't released them to give the Pfizer booster yet.

My doctor's office has Moderna - and the FDA did authorize "mix-and-matching" of the vaccines -  but still only for select populations.

Regardless, though we wanted Moderna to begin with, we're going to stick with Pfizer just because we already know what to expect. 

Either way, how will these claims be billed/handled if the shot is given before official FDA label approval?

However, I do know even the uninsured are covered for vaccines, but I don't know how that billing works.

So the CSR with my insurance company does not know - I'm on hold right now, as he's speaking with his supervisor to get clarification on that. 

Okay, he just came back and his supervisor doesn't know - they're transferring me to the pharmacy-claims team.

I'll update if/when I know more. 


UPDATE:      The pharmacy-claims team does not know either.  


I then called the local news station (WLEX-18) which announced Governor Beshear's authorization, to see if they had any more info on how the billing will be handled. 

They said they didn't know either, it's a good question.

HOWEVER -  they said FDA is scheduled to make that decision to add all adults to the labeled indication for the booster tomorrow, Friday, November 19th - and the feeling is it's likely to get approved for all adults, thus why Governor Beshear went ahead and announced his authorization.

(Of course, that's if there's  no delay in that FDA decision via debate, like last time.)

Thus, here's what I'm going to do/my advice wait until the FDA official approves all adults on its labeled indication - which hopefully is tomorrow -  THEN get the booster -  that should avoid any billing hassles.

I know we wanted the booster before Thanksgiving to avoid the Thanksgiving surge, like we had last year, but I'd still wait just to avoid any possibly billing issues.

Otherwise, posting will be light as I'm preparing for the Thanksgiving holiday :)

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