Consumers may be charged at the counter for COVID antiviral treatment starting this week, as the federal coverage for such drugs ends.
Veterans, uninsured people, and those on Medicaid or Medicare won’t be charged for treatment, but those with private health insurance may be asked to pay up.
The cost of antiviral COVID treatments this week shifted to private insurers as federal coverage for COVID drugs ends. But those on Medicaid, Medicare and uninsured populations can get free treatment until the end of the year.
For people with private health insurance in San Antonio, it means less access to affordable treatment, experts say. It’s unclear how much those treatments will cost, but it’ll be more expensive to treat COVID.
Oral antivirals like Pfizer’s Paxlovid and Merck’s Lagevrio have been covered by the federal government for the past two years. People have been able to get COVID drugs free through the government’s Test to Treat program, where patients can be tested, treated and prescribed treatment.
In the San Antonio area, there are about 15 Test to Treat clinics at local CVS, Walgreen and CentroMed locations.
The shift is happening because the federal government will no longer buy and distribute COVID treatments. As a result, fewer people will have access to affordable and life-saving treatment, and the shift means more out-of-pocket expenses for San Antonians, said St. Mary’s University associate professor of health economics Belinda Román.
“Out-of-pocket expenses are a shocker,” Román said. “Private insurance companies may pay, but the caveat will be in the copays and deductibles. Lower deductibles mean higher premiums. Lower premiums mean higher out of pocket costs to pay for care and medicines, and much higher deductibles.”
“Add to these the increasing costs of providing care and obtaining supplies — the costs will surely go up,” she said.
According to Coda Rayo-Garza, director of research and data for Every Texan, 48.4% of Bexar County residents have employer-based insurance and 27.4% have private health insurance. Nearly 14% of residents, or 281,358 people, have Medicare coverage alone or in combination with more coverage, and another 387,224 people, or 19.2% of Bexar County, have Medicaid. Only 4.4%, or 89,231 people have VA Health Care coverage.
For San Antonians, this means there will be “more hurdles and hassles” to accessing COVID treatment, said Stacey Pogue, senior policy analyst for Every Texan who focuses on health policy issues.
“Now it’ll be like every other drug on your insurance. There will be more administrative hurdles: You’ll have to figure out which COVID treatment is covered by my insurance, which pharmacy is in network with my insurance, and how much will I have to pay?” Pogue said.
People without insurance are much less likely to fill prescriptions, but even those with insurance may see high copays at the register, like with insulin, Pogue said.
Under an agreement with the government, Paxlovid will stay free of charge for patients insured under the Medicare and Medicaid programs through the end of 2024, and to uninsured and underinsured patients through 2028.
According to the American Medical Association, Pfizer is pricing their five-day course of Paxlovid at around $1,400, but that doesn’t mean that’s what people are going to pay out-of-pocket. But they will end up being “pretty expensive,” said AMA Vice President of Science, Medicine and Public Health Andrea Garcia.
Over the next few months, those with private health insurance may be able to access Paxlovid at no cost. Patient assistance programs under Merck and Pfizer may also help some people with coverage pay for their treatment.
“If someone is at risk for complications and receives a prescription for antiviral pills, COVID treatment will be free through the end of 2024 to people who have Medicare, Medicaid or no health insurance,” the San Antonio Metropolitan Health District said in a statement. “People with health insurance may be eligible for copay assistance from the drug manufacturer.”
Low cost clinics like those run by Centromed, Communicare, University and Methodist Healthcare Ministries are additional resources for people without insurance and that need COVID treatment. People with insurance can use any in-network urgent care, primary care or telehealth provider.
The 2024 ACA Open Enrollment period is also open until January 15, 2024. All ACA plans cover prescription drugs. Metro Health also said increased subsidies were extended through 2025, keeping plans more affordable than in the past.
The antivirals have been proven to reduce the risk of severe COVID symptoms and help keep patients out of the hospital, especially for people with underlying health diseases.
The increase in COVID treatment costs come as San Antonians face difficulty getting appointments and the rising cost of prescriptions, public health officials said on how the pandemic affected access to care.
In a CityFest panel titled, “How Does Bexar County ‘Meet the Moment’ Inclusively” Thursday, panelists said even more people in San Antonio live in poverty and have food and housing insecurities.
Anyone with moderate COVID symptoms that does not require more oxygen can get oral antivirals, or the IV antiviral, remdesivir. Children 12 and up who are at high risk of severe illness can get Paxlovid or remdesivir and adults who don’t have other treatment options can get Lagevrio. Children over 28 days old can get remdesivir.
The Department of Health and Human Services (HHS) encouraged manufacturers, distributors and pharmacies to work together as the federal coverage rolls off, reminding that access to COVID treatments will depend “primarily” on the “arrangements in the private commercial market among each of the particular drug manufacturers and private insurers.”
“It is of paramount importance that these medications remain widely accessible to high-risk patients after commercial distribution begins in order to minimize hospitalizations and deaths from COVID,” HHS said in a letter addressing the rolloff.
The Department of Veterans Affairs and the Department of Defense will keep access to federally acquired Paxlovid.
On Tuesday, the city reported 752 new COVID cases in San Antonio.
Nationally COVID hospitalizations are trending down, and University Health is not seeing a high number of hospitalizations at this time, said University Health spokeswoman Andrea Wazir.
“Our numbers remain very low and flat and we are not seeing any significant trends. The doctor did note that outpatient RSV numbers have slightly increased during the last couple of weeks. We continue to monitor the numbers of all respiratory viruses,” Wazir said.
