CMS released a memo to remind Part D plan sponsors of when $0 cost-sharing applies for adult vaccines covered under Part D. Specifically, CMS reiterated that the effective date of the $0 cost-sharing requirement for a new adult vaccine recommended by the Advisory Committee on Immunization Practices must align with the date on which the CDC Director adopts the respective recommendation, as published on the CDC website. If the CDC does not publish a date on its website, the effective date will be the date after the last day of the ACIP meeting at which the recommendation was approved. The $0 cost-share also retroactively applies to commercially available ACIP-recommended adult vaccines adopted by the CDC Director during previous 2023 ACIP meetings. In addition, CMS reminded Part D sponsors that they must apply $0 cost-sharing for new Part D vaccines that become available during the plan year and have an ACIP-recommended use in the adult population, regardless of whether a Part D sponsor adds such vaccines to the formulary mid-year or the enrollee obtains the vaccine via a formulary exception.
If Part D sponsors add such vaccines to their formulary with utilization management requirements, CMS will review such requirements to ensure they are consistent with the Prescription Drug Benefit Manual. CMS stated that plan adherence to these policies is particularly important as new ACIP-recommended adult vaccines become available, including new vaccines for respiratory syncytial virus, and sponsors should add these high-priority vaccines to their formularies as quickly as possible. CMS stated that questions about this policy can be submitted to [email protected].
