Some older Americans on Medicare are facing an unexpected problem: The updated Covid shots — approved last month by the Food and Drug Administration for all adults 65 and up — aren’t being covered, forcing them to decide whether to pay out of pocket.
Allison Engel, 74, said she visited her CVS in Pasadena, California, on Tuesday, where she was told the shot would cost $225 out of pocket.
“They typed everything in, and handed me a rejection letter,” Engel said. “They told me it wasn’t in the Medicare system yet and I should come back in two weeks.”
Engel didn’t want to wait, so she paid out of pocket, and hopes Medicare will reimburse her.
Brant Mittler, 78, of San Antonio, said he and his wife stopped by their CVS pharmacy on Monday where they ran into the same issue.
“The pharmacist tells my wife, ‘We’ve had Medicare patients coming in all day, and everybody’s upset because we can’t give it,’” he said. Mittler said they got their Covid shots Thursday after the pharmacist said Medicare had updated the system there.
Their experiences are at odds with remarks from Health Secretary Robert F. Kennedy Jr., who told a Senate committee on Thursday that most Americans are going to be able to get a Covid shot from their pharmacy for free. As HHS secretary, Kennedy oversees Medicare.
Late last month, Kennedy announced that the FDA had approved updated Covid shots for the fall, but for a smaller, high-risk group: People 65 and up and those with underlying medical conditions.
The limited approval raised concerns about access for people outside the high-risk groups, but not for those eligible.
“Anybody can get the booster,” he told members of the Senate Finance Committee, when pressed about the limited eligibility. “Most Americans will be able to get it from their pharmacy.”
Arthur Caplan, the head of the division of medical ethics at NYU Langone Medical Center in New York City, said if eligible patients are having trouble getting the vaccine, it heightens his concerns about limited access to vaccines under shifting policies from Kennedy.
“Medicare should be covering the shots, but it isn’t clearing people,” Caplan said. “So again, this just stirs up uncertainty about, ‘OK, am I eligible? Am I in the risk group?’ People still aren’t sure.”
The updated Covid shots began arriving at major pharmacy chains last week.
But some say they’re holding off in certain states until the CDC’s vaccine advisory committee issues its own recommendation on eligibility.
The CDC’s Advisory Committee on Immunization Practices typically meets earlier in the summer to make its Covid vaccine recommendation. This year, the group isn’t scheduled to meet until Sept. 18.
Medicare, however, doesn’t need to wait for CDC’s sign-off. Once the FDA approves a vaccine, Medicare has the authority to cover it, said Dorit Reiss, a vaccine policy expert at the University of California Law, San Francisco.
CVS, one of the nation’s largest pharmacy chains, said that in 13 states and Washington, D.C., everyone, including Medicare patients, will need a doctor’s prescription until ACIP issues its recommendations — and even then, eligibility will depend on age. In three states — Massachusetts, Nevada and New Mexico — CVS won’t be offering the Covid shot at all until ACIP acts.
“A few payers are still updating their systems and may not yet be set up to cover the updated Covid-19 vaccines,” CVS spokesperson Amy Thibault said when asked about some Medicare patients who were told the vaccine wasn’t covered.
“If this happens, our pharmacy teams can help patients schedule an appointment for a later date,” Thibault said.
Walgreens did not respond to a request for comment.
A spokesperson for the Centers for Medicare and Medicaid Services said in an emailed statement that the agency was looking into the issue.
“CMS continues to monitor developments related to COVID-19 vaccines,” the spokesperson said.
