How is the COVID-19 vaccine covered under my Plan?

National General Benefits Solutions*

COVID-19 Vaccine FAQ – December 23, 2020

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At National General Benefits Solutions, we continue to monitor the COVID-19 outbreak and provide you with updates as they are available. As of Friday, December 11, 2020, the FDA has granted Emergency Use Authorization (EUA) for** Pfizer-BioNTech’s COVID-19 vaccine,** and on Friday, December 18, 2020, the FDA granted EUA for Moderna’s COVID-19 vaccine. Additional COVID-19 vaccine approvals may be coming.

Here are some answers to common questions you may have about the COVID-19 vaccine and how it will be covered under your health benefits plan.

How is the COVID-19 vaccine covered under my Plan?

FDA- and EUA-approved vaccines are covered as a preventive service at 100%.

Initially, the cost of the vaccine itself will be paid in full by the government.

Charges for administering the vaccine will be covered under the Plan Clinical Preventive benefit. This means it is covered at 100%, with first-dollar Plan payment, which is not subject to any deductibles, copays, or coinsurance.

Medical Provider Administration

100% preventive coverage for administration of the vaccine applies to both in-network and out-of-network medical providers. This coverage includes the cost of an office visit when delivery of the immunization is the primary purpose of the visit.
For members who obtain the vaccine from an out-of-network provider and for members covered by plans without a network, the plan will pay 100% of the Maximum Allowable Amount per the terms of your Summary Plan Description. Your provider should not balance bill you for amounts in excess of the reimbursed amount.

Pharmacy Administration

100% preventive coverage for administration of the vaccine applies at both in-network and out-of-network pharmacies.
Most pharmacies are part of the Cigna Pharmacy Network. Cigna network pharmacies will submit your claim to the Plan for 100%, first-dollar coverage.
If you receive the vaccine from an out-of-network pharmacy, you will pay the administration fee out-of-pocket at the pharmacy, but the administration fee will be reimbursed at 100% when you submit a completed Claim Form to your plan administrator. If you have questions regarding this process, please call the number on the back of your ID Card.

Who is eligible to receive the COVID-19 vaccine?

Due to limited supply of the COVID-19 vaccine, FDA- and EUA-approved COVID-19 vaccines will be available in a phased approach to different populations based on the CDC’s Advisory Committee on Immunization Practices (ACIP) guidance.

The first phase of vaccine distribution will be allocated to health care personnel and long-term care facility residents. To find out more visit** https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html.**

Where can I get a COVID-19 vaccine?

When COVID-19 vaccines become more widely available, it will be distributed by CDC-approved medical providers and pharmacies. Additional information will be released when the vaccine becomes more widely available.

How do I know that a COVID-19 vaccine is safe and effective?

To learn more about how the CDC ensures safety of COVID-19 vaccines in the United States visit https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety.html.

Where can I learn more?

If you have more questions regarding the COVID-19 vaccine and its distribution, please visit CDC’s website at** https://www.cdc.gov/coronavirus/2019-ncov/vaccines/8-things.html.**

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*The National General Benefits Solutions (NGBS) Self-Funded Program provides tools for employers owning small to mid-sized businesses to establish a self-funded health benefit plan for their employees. The benefit plan is established by the employer and is not an insurance product. For employers in the NGBS Self-Funded Program, stop-loss insurance is underwritten by: Integon National Insurance Company in CO, CT, NY and VT; Integon Indemnity Corporation in FL; and National Health Insurance Company in all other states where offered. National Health Insurance Company, Integon National Insurance Company, and Integon Indemnity Corporation are rated “A-” (Excellent) by A.M. Best.