Medicare won't cover Paxlovid twice within 6 months

[xpetes]

I figured this is worth sharing - as I was shocked to have gone through this, but I found a solution worth sharing that even my pharmacist didn't know about.

Yes, I think we all know by now that if you have CLL its important to get Paxlovid if you get COVID (and it really works well). I had COVID in April 2024 and got Paxlovid. I just got it again less then 4 months later. I have a Medicare Part D drug plan and went I went to get my new prescription filled, I was told Medicare denied coverage. When I called to find out why, I was told that there is a limit of one 'script for Paxlovid every 180 days. Apparently you're not allowed to get COVID 2x in 6 months? Or maybe Medicare would rather pay for your hospital admission when you get really sick instead of filling this prescription?

Anyway, I luckily stumbled on a Pfizer program that covered it in full for cases like this. Here is the link:

paxlovid.iassist.com/

Note that my pharmacist has seen this situation several times already and wasn't aware of this, so I figured it was worth sharing.

PS. If you don't have insurance or get this coupon, the cost is $1500

[Panz]

Thank you for sharing this!!! This is huge!

I see you are new to our community and we are so happy to have you participate…we are in this together and help whenever we are able.

All the very best to you as you continue on your journey. Do you yourself have CLL?

Panz 👍😎🥵☔️💕🪭🫠

[xpetes in reply to Panz]

Yes, I have CLL. And I've published several posts before, so not sure why I would appear as new (?).

[SofiaDeo in reply to xpetes]

You don't appear as "new", just, your bio doesn't have much. It doesn't say why you are in this group; patient, caregiver, etc. Your profile doesn't have a location, this post is unlocked. Thus you appear to be somewhat a "newbie." Since this is a UK based support group, at least one's country is desirable IMO if not in the UK. Your post title more or less assumes everyone knows what Medicare is, but it's a US thing only, and your country should reflect that since it's not relevant to where this support group is based.

[AkimTamiroff]

People who try to use the Pfizer discount program should make sure they get the discount up front from the pharmacist – if you pay full price and have to try to get a refund from Pfizer, prepare for an endless runaround.

Under the Paxcess program I used, you are supposed to download a co-pay card and then present it to your pharmacist and you can then typically get Paxlovid for free. This program is currently scheduled to expire at the end of the year. Information is here:

paxlovid.com/paxcess?cmp=e5...

Pfizer has not designed the policy to make it easy for people to get the discount. Its policy is that you can’t sign up for a co-pay card until you actually have a prescription – which usually means you have to sign up when you’re already sick with Covid. But once you have Covid, you have to use Paxlovid quickly to get the benefit (not more than 5 days after getting symptoms), which means people have a very narrow window. Your pharmacist is supposed to advise you about this, but (as xpetes found) they don’t always do so. The U.S. Secretary of Health and Human Services had a well-publicized meeting on January 22 to complain about this – see hhs.gov/about/news/2024/01/....

I would strongly urge you to make sure you get any discount up front and not rely on paying for it and then getting a refund from Pfizer. I needed Paxlovid last December and the pharmacist didn’t advise us about the Paxcess program, so we paid full price. I then found out about the program and tried to get a refund through Pfizer, and it was a nightmare.

The refund form specifically said to include the original pharmacy receipt and that “Cash register receipt is not valid.” I submitted everything they wanted and kept calling them to check the progress of my application. It took months, and then they turned me down on the ground that I had provided the pharmacy receipt but hadn’t included the cash register receipt! Yet their rebate form continues to tell people that they only want the pharmacy receipt, not the cash register receipt. It certainly raises questions about Pfizer’s good faith. (Fortunately I subsequently managed to get a refund directly from the pharmacy.)

[xpetes in reply to AkimTamiroff]

Akim, I had a chance to read the link you provided, thank you for providing that. Apparently my (USA based) Medicare part D was mandated by the HHS to cover paxlovid and they were wrong to deny it. I do plan to send in a complaint to them! Wondering if there is a watchdog agency that should also be notified?

Apologies to our Ozzie friends and others around the world, this is a USA based issue - I had no idea other countries also have medical insurance called Medicare!

[xpetes]

Yes, in my case I had the coupon with all the codes and confirmed with the pharmacist that it was covered in full (free) before I had them fill it. I did not do the pay cash now, and try to get reimbursed route. But now that anyone reading this knows, there is no reason go pay now try to get money back later.

To your point that you need the prescription first, well yes, no matter what insurance you use, or this program, you need a prescription to get this med. I'm not sure why you would try to get this drug before you need it (meaning you would have come down with COVID). I would hope that like anyone with CLL and a decent oncologist should be able to get a prescription called in for Paxlovid after testing positive with one phone call to their office! And once you have that, if you use this program it was instantaneous to get the coupon and then the pharmacist was able to promptly enter the codes and fill it on the spot. So in my case, my only delay was because the 1st time I went to get it filled they denied the coverage and I went home empty handed and then figured this other way out and went back the next day.

And yes, you want to start taking this med ASAP, so you are correct, don't waste time!

Gotta love insurance. This is my first year on Medicare. Up to now it was great!

[Tangolover]

Thank you!

[AkimTamiroff]

Thanks, xpetes, one thing that may be worth mentioning is that I understand that there are some people with CLL who have been able to get their doctors to prescribe them Paxlovid before they get Covid. The purpose is to make sure that these patients can take Paxlovid as soon as they test positive, without having to go through the rigmarole of getting a prescription and picking up the medication when they are already feeling poorly. One advantage of this is that at least some experts say that the quicker you take Paxlovid after getting symptoms (and testing positive), the better. The New York Times (Jan. 11, 2024) quoted Dr. Ziyad Al-Aly, chief of research and development at the Veterans Affairs St. Louis Healthcare System, as saying “The earlier you get it, the better it works.” It also prevents problems in case a shortage develops. (Of course, anyone who does this will need to make sure the medication hasn't expired in the meantime.) I haven't done it myself, but I imagine this might be particularly useful for people who don't have someone they can rely on to pick up a prescription for them quickly.

[Covidpart4]

This just happened to me today as I tested positive for COVID 4 months after the last time and was denied. I downloaded the card and will try again tomorrow with this but not confident I’ll be successful. Thank for giving me some hope albeit if only for a night.

[xpetes in reply to Covidpart4]

It should work.. Let us know if you succeed?