As 2024 inches closer, COVID-19 is unfortunately still very much with us.

Ever since the drug Paxlovid was authorized by the Food and Drug Administration (FDA) back in December 2021, requesting this antiviral pill has been part of many people’s COVID plans for treatment and recovery for the last couple of years.

But now, starting this month, a few changes to how Paxlovid is funded are here — which could potentially have consequences for how you request and access the drug. And if you’ve asked for Paxlovid before or plan on seeking out the antiviral drug if you get COVID, there are some updates you might not necessarily expect.

Paxlovid has been proven to be highly effective at reducing severe disease and hospitalization from COVID, and there’s now also evidence it can help reduce the risks of long COVID, too. The drug has also been free by prescription in California for patients with mild to moderate illness “with risk of progression to severe disease,” according to the California Department of Public Health (CDPH). The agency notes that many common conditions might qualify you for this, including physical inactivity, obesity and depression.

Keep reading for everything you need to know about requesting Paxlovid in or after November so you’re prepared for any bumps along the way. If you’re met with unexpected Paxlovid charges, this information might help you understand why that’s happening — and how to avoid or challenge those new costs.

Jump straight to:

• If you have health insurance: How to avoid new potential costs for Paxlovid
  
• If you don’t have health insurance: How to find free Paxlovid

Paxlovid is transitioning to the commercial market

Like COVID vaccines (more on that below), Paxlovid supplies in the United States are moving away from being bought by the federal government and into the commercial market — like countless other drugs.

The government paid Pfizer, the makers of Paxlovid, around $530 per course of the drug. Now, Pfizer said the company has set the price of Paxlovid at around $1,400 per five-day course, and commercial ordering of the drug began on Nov. 1. Regardless of this change, health insurers still have to cover your Paxlovid (more on that below).

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There’s also a Paxlovid alternative called Lagevrio (molnupiravir), which is undergoing the same transition to the commercial market this month. While the FDA’s data has shown that molnupiravir is a less effective drug than Paxlovid, doctors may still prescribe it instead for several reasons, including the risk of Paxlovid’s interactions with other medications you’re taking.

This move follows the trend of COVID care transitioning away from federal funding and into the traditional commercial health care market. This is also what’s happened with the new COVID vaccines now available in the U.S., which is why these kinds of vaccines were once offered at government-funded vaccination sites but are now being offered through providers and paid for by any health insurance you have.

In the earlier years of the pandemic, the federal government paying for COVID care was “a way to sort of just get a lot of people covered and then … figure out the financing after the fact,” said Anthony Wright, executive director of consumer advocate group Health Access California.

“But these resources are still available for folks, and people should take advantage of them, even though there’s no longer sort of a federal blanket policy,” Wright said. “It’s now more of a patchwork policy depending on your plan, depending on your location, etc.”

The takeaway: Paxlovid’s entry into the commercial market, with a much higher sticker price, means that any out-of-pocket costs could potentially be far greater. Hopefully, you won’t have to pay them.

There’ll still be a federal stockpile of Paxlovid (for a while)

Because the federal government did buy so much Paxlovid from Pfizer during the last couple of years, there’s still what a U.S. Department of Health and Human Services (HHS) official described as “an ample supply of federally-owned therapeutics with millions of treatment courses still in the field.”

The existence of this federal stockpile means that until Dec. 15, health care providers can still order Paxlovid from the government — rather than Pfizer — to distribute until supplies run out.

Federally purchased Paxlovid has been prescribed free so far during the pandemic, and the California Department of Public Health (CDPH) said that these supplies “will remain free to all patients regardless of insurance status.” This free federal supply is “expected to last through the end of the year in most areas, although this will vary depending on demand,” CDPH said.

Once that supply runs out, “the price of commercial product will depend on the individual’s insurance.” But because you won’t necessarily know if you are indeed getting Paxlovid free from the government and not purchased from Pfizer, if you have health insurance, it’s important to make sure you’re getting your prescription “in-network.” Jump straight to more information about getting Paxlovid through your health insurance. 

The takeaway: If you are prescribed Paxlovid in the next few months, you could be getting a course that came straight from the government’s own supply rather than one purchased from Pfizer. 

Federal stockpile or not, your California health insurer still has to cover Paxlovid

We’re now six months out from the end of the federal public health emergency for COVID, which ended on May 11 and had big effects on nationwide funding for COVID vaccines and testing. But thanks to laws passed in California during the pandemic, Californians kept a lot more COVID coverage than folks living in other states. Specifically, State Bill 1473 required insurers to keep covering the costs of COVID therapeutic treatments like Paxlovid, as well as reimbursing their members for the costs of up to eight over-the-counter COVID tests a month after the end of the public health emergency.

The California Department of Managed Health Care (DMHC) said that health plans regulated by their agency — which includes HMO plans and “some other kinds of plans” — “must cover COVID-19 tests, vaccines and treatment with no health plan prior authorization.” California law said the DMHC “also prohibits cost sharing and utilization management for therapeutics/Paxlovid, similar to testing and vaccines.”

The takeaway: Your health insurer can’t deny you coverage of Paxlovid. But that said …

If you have health insurance, be sure to request Paxlovid “in-network” for it to be covered starting Nov. 12

That California law also forced insurers to cover these costs regardless of whether a patient sought COVID services “in-network.” But it only kept the current situation in place until six months after the end of the federal emergency — a period that ended on Nov. 11.

Previously, Paxlovid supplies were funded by the federal government and were free regardless of health insurance status —  so the concept of getting your Paxlovid “in-network” just didn’t apply. But as California reaches that “six months after the end of the federal emergency” mark, it means that starting Nov. 12, insurers can require their members to obtain certain COVID care and treatment “in-network.” And, confirms DMHC, “after November 11, if [patients] access the services from an out-of-network provider, they may be charged cost-sharing, such as a co-pay or co-insurance.”

DMHC stresses that “if health plan members access these services from a provider in their health plan’s network, they will not need to pay anything for these services.” Going out of network after Nov. 12 could look like getting a telehealth visit with a provider who’s not in your health plan’s network or using an out-of-network pharmacy for the Paxlovid prescription, if your plan requires you to only use certain pharmacies.

“It’s hard to give blanket advice because it really depends plan by plan,” said Health Access’ Wright, but “in general,” he stresses that people should now seek their COVID treatment, or their COVID vaccine, “in the way that they have normally got other health care through their plan.”

“As long as you are getting the care in the way that you have typically got other care, including other prescriptions … then you should be OK,” Wright said. “You can double-check with your plan if you’re worried about it.”

What if you believe you’ve been wrongly charged for the cost of Paxlovid — or a COVID test or vaccine, for that matter? DMHC said that if you get a bill you don’t believe you should be paying for, such as a “qualifying” treatment, you “should first contact [your] health plan to file a grievance, sometimes called an appeal, and include a copy of the bill.”

If you “do not agree” with your health plan’s response to your grievance, or “if the plan takes more than 30 days to fix the problem,” DMHC advises contacting their Help Center online or calling them at 1-888-466-2219.

Your health plan should also not claim you have to go out-of-network to get COVID care, Wright said.

“If your plan is not providing you access to any of these therapeutics or tests or treatments, then they’re violating the consumer protections of what you’re entitled to as a plan member,” he said.

“Yes, it will need to be in network, but [plans] are required to provide that in-network care in a timely fashion,” he emphasized. “And if they don’t, that you have a right to complain [to DMHC] and get that care.”

“You don’t have to go out-of-network and deal with a big bill,” he added.

The takeaway: If you have health insurance, be certain you’re going in-network to request and pick up Paxlovid after Nov. 12.

If you don’t have insurance, Paxlovid will still be free

If you don’t have health insurance and have wanted Paxlovid for the last few years, the California Department of Health (CDPH) advises using Sesame Care, California’s COVID telehealth service.

This program is intended “to support uninsured and underinsured individuals within the State of California who cannot connect with a healthcare provider within 24 hours of receiving a positive test result,” CDPH said. Uninsured folks should visit sesamecare.com/covid to make a free phone or video appointment through Sesame Care or call (833) 686-5051 (6 a.m. to 4 p.m. PT, seven days a week). When you speak to a provider through Sesame Care, they’ll prescribe you Paxlovid if you’re eligible, and it will either be mailed to you or made available at a nearby pharmacy.

This Sesame Care consultation and the Paxlovid prescription should be free. Sesame Care’s site said that if you are asked to pay for any of these services, you should call Sesame Care at (888) 897-1244 so they “can follow up with the pharmacy.” CDPH confirms that this service “will continue to provide free appointments through February 2024.” (Be careful only to use Sesame Care’s free COVID care webpage at sesamecare.com/covid and not click away to other parts of Sesame Care’s website. Sesame warns that if you enter Sesame Care’s regular website, you’ll be charged for its services.)

In the long term, the Department of Health and Human Services (HHS) said that the costs of Paxlovid for uninsured and underinsured will be covered through a separate federal program through 2028.

If you have health insurance, you can also use Sesame Care for a free telehealth appointment if you haven’t been able to connect with your regular health care provider within 24 hours of receiving a positive test result, according to CDPH. But bear in mind that CDPH also said that “the cost of the medication may vary on the patient’s insurance status after commercialization of Paxlovid/Lagevrio begins in November.”

Remember, the federal stockpiles of these drugs will still be around for a while, and CDPH confirms that “federally purchased COVID-19 medications that are still in supply will remain free to all patients regardless of insurance status.” But “once the federal supply runs out, the price of commercial product will depend on the individual’s insurance,” the agency said.

If you have health insurance, be very clear about that detail with the telehealth provider you speak to through Sesame Care, and ask if it’s possible to know whether any Paxlovid prescription you get is coming from that free federal stockpile and whether you should anticipate any cost-sharing from your insurance for getting the prescription through Sesame Care.

The takeaway: Don’t panic about the new commercial sticker price of Paxlovid if you don’t have health insurance — there are still ways to get it for free. 

The official eligibility criteria for a Paxlovid prescription hasn’t changed (yet)

Back in December 2021, Paxlovid was the first oral antiviral treatment for COVID authorized by the Food and Drug Administration (FDA). Due to limited supply, Paxlovid was initially only used to treat the patients deemed most at risk from severe illness from COVID — but later in 2022, it was expanded to more pharmacies across the United States as part of a nationwide push to get Paxlovid to more COVID patients who could benefit from it due to existing health factors.

California even sent out an advisory to health care providers in December 2022, reminding them of “ample supply” and urging them only to refuse to prescribe Paxlovid in “situations in which the risk of prescribing clearly outweighs the benefits of treatment in preventing hospitalization, death, and the potential for reduced risk of long COVID.”

The state’s most up-to-date guidance for Paxlovid prescriptions comes from the National Institute of Health (NIH), which notes that the drug is recommended for people with “mild to moderate COVID-19 who are at high risk of disease progression.” As for what constitutes that “high risk,” NIH follows the CDC’s list of medical conditions that might potentially put a person at higher risk of severe disease, hospitalization or death from COVID, which includes immunocompromise, disabilities, mental health conditions including depression, body mass, physical inactivity and being a current or former smoker.

So will Paxlovid’s move to the commercial market (and differences in how you access a prescription in-network) change who’s eligible to be prescribed the antiviral? When KQED asked CDPH, the agency said they would continue “to review and update guidance” and pointed to the NIH’s Paxlovid guidance as “the most up-to-date.”

Health Access’s Wright said that as the price of Paxlovid goes up, insurers might as well “be more watchful about those guidelines,” but that “it shouldn’t have an impact on people’s out-of-pocket [expenses], even if it does provide a cost that we all will bear with the premiums.”

The takeaway: If you test positive for COVID, it’s still worth asking your provider whether you’re a good candidate for Paxlovid — even if you don’t consider yourself “high risk.” 

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At KQED News, we know that it can sometimes be hard to track down the answers to navigate life in the Bay Area in 2023. We’ve published clear, practical explainers and guides about COVID, how to cope with intense winter weather, and how to exercise your right to protest safely.

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