Understanding the Reimbursement Issues for Pharmacies Around COVID-19 Vaccines

Susan Lang, CEO of XIL Health and former senior executive at Express Scripts, discusses some of the reimbursement issues that have been arising for pharmacies while administering COVID-19 vaccines.

Pharmacy Times interviewed Susan Lang, CEO of XIL Health and former senior executive at Express Scripts, on the losses that pharmacies have experienced due to the COVID-19 pandemic.

Alana Hippensteele: As pharmacies work to administer COVID-19 shots, some reimbursement issues have been arising. What are some of these reimbursement issues, and why are they causing problems for pharmacies?

Susan Lang: So, the COVID-19 vaccine is really unique in that it's not a private supply chain. So, when I say private supply chain, they're not out buying a vaccine through their group purchasing organization or through their drug wholesaler, they're getting that from the federal government.

So, the federal government is buying those vaccines from the drug manufacturers, and then giving those based on whatever the population is to the pharmacies or to other providers who are giving the shots. So, that's one issue. So, it's a very unusual circumstance from that perspective, where the government is buying the drug.

The second issue is the reimbursement then on the vaccine itself. So, in the private sector, everyone has been following what the Centers for Medicare & Medicaid Services (CMS) pays for the shots.

So, CMS came out with a 46 dollar payment for both shots combined, so it's about 23 dollars a shot. Some of the PBMs and the health plans couldn't administer a 2-shot vaccine and pay correctly. The first payment was different from the second payment and their systems didn't do that, and some tried to negotiate to get a margin off of what CMS was paying.

So, in the middle of all of this, you have pharmacies now scrambling and health plans honestly scrambling to get paper back and forth to make sure they have amendments and they have contracts signed so they can get paid at all for any of this. So, the health plan and the PBM will pay for the administration of the vaccine, while the government paid for the drug itself.