In most cases, flu vaccines are covered under both the pharmacy and medical benefit plans. This is a good thing, as more options for access often translate into more people being vaccinated. With the 2017-2018 flu season having been one of the deadliest in recent years, flu vaccinations are the simplest, most common sense preventive measure available.
The question that often arises, however, is whether there are differences in cost for flu vaccines between the pharmacy and medical benefits—is one less expensive than the other? As is so often the case, the answer is, “It depends…”
Using internal data, Excelsior Solutions has been able to determine that the ingredient cost of flu vaccine itself is generally lower, on average, in the medical benefit than in the pharmacy benefit. Once the cost of a doctor office visit is factored in on the Medical benefit, however, and once the pharmacy administration fee is accounted for, the cost advantage shifts to the pharmacy benefit. While the total cost (vaccine + fees) is nominally lower under the pharmacy benefit, it is not a material enough difference to justify making flu vaccines exclusively available under the pharmacy benefit alone.
Allowing flu vaccines to be administered in doctors’ offices and pharmacies (as well as in other non-physician locations such as urgent care centers, grocery stores and community-based clinics) increases convenience and access, both of which are key drivers in increasing vaccination rates.
While specific data are sketchy, at least one report indicates that, overall, more than two to three times as many patients choose to receive their flu vaccine from their physician in an office setting than in a pharmacy or other non-physician office location.
Bottom Line for Clients: Being vaccinated for flu is better than not being vaccinated for flu, and the best location is wherever it can most conveniently be obtained. Cost ought not be a driver for selecting a location, as there isn’t a significant total cost difference between the pharmacy and medical benefits. If patients have a regularly scheduled doctor appointment in the September through early November time frame, then they should ask for their annual flu vaccine during that visit. Patients should not feel obligated to make a special doctor office appointment solely to obtain a flu vaccine, but certainly can if they choose to. Patients who do not have a doctor visit scheduled during the September through November time frame should be encouraged to receive their flu vaccine through one of the many alternative sites that are available, with pharmacybased sites under the pharmacy benefit having a slight cost advantage.
If you would like to discuss flu vaccines, or any other aspect of your pharmacy benefit plan, simply reach out to your Excelsior Solutions account team and we will be happy to quickly set up a call.
Until next time…
Bob has more than 30 years of diverse experience in the pharmacy industry. Over the course of his career, Bob has led clinical and PBM operations teams in successfully managing more than $4 billion in annual drug spend. This was also while limiting per-member-per-year spending growth to levels that have simultaneously drawn industry acclaim and consistently high levels of member and payer satisfaction.