Now that the antiviral Paxlovid is no longer routinely covered by insurance or by the government as a Covid treatment, can you get it free? How much will you pay?
Well, it could be free, we learned. Or it could be $500 to $1,400. Or it could be $1,600 or $1,500 — or $6.50, or $75.90 for the standard five-day dose. As with so much in the U.S. healthcare market, it depends
In October, the Department of Health and Human Services said you might be covered at least for the next few weeks if you are uninsured or on Medicare or Medicaid. The rules are likely to change at the turn of the year, though.
“As the federal government transitions away from distributing these products, access will primarily depend on the arrangements in the private commercial market among each of the particular drug manufacturers and private insurers,” H.H.S. wrote. “We .. share here our best understanding to date. For Paxlovid, during this transition and through the end of 2024, people who are uninsured and those who have Medicare or Medicaid coverage will continue to access Paxlovid with no out-of-pocket costs through Pfizer’s new patient assistance program.
“Federal entities such as the Indian Health Service, the Department of Veterans Affairs, and the Department of Defense will retain access to Federally-acquired Paxlovid, as they have accessed the product for the last two years. We expect that individuals with private insurance will continue to be able to access Paxlovid as coverage is established over the next few months. Pfizer has also stated that it is setting up a co-pay savings program for those with private insurance, which will be independent of the patient assistance program.”
This is a departure from common practice, in which the patient assistance programs the drug companies set up to reduce patient out-of-pocket costs (and to gain tax breaks) are typically not available to people covered by Medicare, Medicaid or other public insurers.
For another treatment, the lesser-known Lagevrio, there will also be a “transition on November 1, 2023, as an option for eligible individuals who are unable to take Paxlovid or Veklury. Again, we expect there to be commercial coverage for Lagevrio as well, but for those who cannot afford the product, the Merck patient assistance program will be available to assist certain patients,” H.H.S. wrote.
Veklury (Remdesivir) is an IV antiviral. No information about pricing or insurance or co-pay coverage was immediately available.
Payment assistance
There may be patient assistance programs for Paxlovid for those with private insurance. the manufacturer, Pfizer, is offering a coupon program, called “Paxcess,” which may bring your price to $0 if you are commercially insured. It won’t work for people insured by Medicare, Medicaid or other public insurance. You’ll need to fill out the paperwork to see if you qualify. As always, the patient assistance programs may have limits, and they may not be quick to get off the ground.
Meanwhile, confusingly, while the federal government is “transitioning away” from covering these products, as H.H.S. said above, the Home Test to Treat from the National Institutes of Health should supply Paxlovid free.
Go to http://Test2Treat.org to enroll for free. This applies “if you are an uninsured or underinsured adult (18+), on Medicare, Medicaid, in the VA healthcare system, or receive care from the Indian Health Services. Upon enrollment, when not currently positive, you can receive free tests shipped directly to you and, if you later test positive, you can receive free telehealth care and treatment (if prescribed).”
“If you are currently positive for COVID-19 or Flu (Influenza), you can enroll to receive free telehealth care and treatment (if prescribed). Please note that if enrolling while currently positive, you will not have access to free tests. Please note, this program is free, and we will never request your specific payment or insurance information, nor will bill or contact any insurance provider you may have. You must be at least 18 years old.”
Price is a barrier
Pfizer’s pricing of Paxlovid has caused a great deal of consternation among public health officials. Price is a barrier, of course. And while it’s not completely clear that Paxlovid helps every patient have an easier course of the disease, or that it helps avert Long Covid, it is widely recommended as one of the only treatments (another is the common and inexpensive generic diabetes medication metformin.”
“Paxlovid is being privatized (i.e., no longer covered by government),” Katelyn Jetelina, who writes as Your Local Epidemiologist on Substack, wrote recently. “Pfizer also announced an astronomical price: $1,400. Cost is a legitimate reason not to get it, which is devastating and ridiculous.”
Merck has not said what the list price for Lagevrio will be, according to the Associated Press. While we could not find any information about that that is recent, a summer GoodRX article said the cost is $700 cash. It seems possible that there are similar considerations on whether it will be covered to the considerations regarding Paxlovid. Lagevrio has been approved only for people 18 and older; Paxlovid is approved for people 12 and up.
This is not medical advice: Not everyone should take Paxlovid or Lagevrio. There are various counter-indications. Various medicines have drug interactions with Paxlovid; find a list on this page for co-pay assistance for Paxlovid drug interactions. Talk to your doctor.
Gaining access to Paxlovid has not always been easy. Some doctors refuse to prescribe for anyone who is not over 65 or at increased risk.
In May 2022 we posted this article about difficulties in getting Paxlovid by Jacqui Neber.
We heard in 2022 of two healthy 20-something New York City women, testing positive at the same time; one got Paxlovid easily and the other could not gain access.
Cities and other cases
Some cities and states may have local programs for Paxlovid. The New York City hotline, for example, should be able to deliver Paxlovid. Call 212-COVID19 (212-268-4319). The program is managed by New York Health + Hospitals, the big public hospital system.
The University of Utah health system has this Covid treatment locator.
The state of Minnesota has a test-to-treat program.
There are several online services. Callondoc says it charges $39.99 for a visit to get Paxlovid. HiDrB says its consultation is $15.
Some people are still unable to get it. One woman tweeted: “Grandma Val caught Covid while she was in the hospital. She’s in a rehab facility, in isolation, and getting worse by the day. They couldn’t give her Paxlovid because it wasn’t covered by insurance and it would have cost $1,000 out of pocket. Please send healing thoughts her way. I cannot lose her yet. 2023 has brought enough tragedies as it is.” She wrote that her grandmother is on Medicare.
One woman wrote on Twitter: “Just diagnosed today, here in the US. Doc visit, very thorough, chest Xray, script for Paxlovid. No US health insurance, cost $0. Script dispensed at pharmacy, $6.50.”
Another: “I got Paxlovid at no cost through my healthcare provider”
Another: “I paid out of pocket Aug 22 for Paxlovid cost me $75.90”
Another: “My paxlovid just cost $1600”
Another: “Hubby has Covid…we’ve tried very hard to avoid it. I’m negative so far, masking and distancing. He was prescribed paxlovid, our HEB pharmacy was out in all three locations in town, closest availability nearly two hours away and cost was $1600! We found it at CVS, free.”
Outdated information online
It is easy to find conflicting information online. Here are two sources that appear to be outdated, but still appear online:
In May, Medigap.com said no: “Paxlovid is an experimental oral COVID-19 treatment, and as with other experimental treatments, it’s not covered by Medicare. This is because Medicare does not cover any experimental treatments that have not been proven to be safe and effective. Therefore, if you are seeking therapy for COVID-19, you may not be able to have Paxlovid covered by Medicare. However, depending on the plan, you may receive some coverage through other insurance plans.”
For Medicare subscribers, GoodRX says no: “In general, Medicare prescription drug plans (Part D) do not cover this drug. Be sure to contact your specific plan to verify coverage information. A limited set of drugs administered in a doctor’s office or hospital outpatient setting may be covered under Medical Insurance (Part B).“
What you can do
There are no one-size-fits-all answers here, but here’s a start.
Consider registering for TestToTreat.org, run by eMed, funded in whole or in part with Federal funds from the National Institute of Biomedical Imaging and Bioengineering, National Institutes of Health and the Department of Health and Human Services. It seems to run after Jan. 1. You need to register first to have access to Paxlovid. Some conditions apply.
The Patient Support Program from Pfizer may offer access. As near as we can tell, it operates like other patient assistance programs — not available for Medicare, Medicaid, Tricare and other government-supported insurance programs. Other conditions may apply.
See if there are city or state programs, or hospital programs like the Utah, Minnesota and New York City ones above.
Check with your insurer.
It seems to be true from what’s above that at least for now, people insured by traditional Medicare and Medicaid are covered at no cost. But if it’s Medicare Advantage, the privatized version of Medicare — we don’t know. The privatized plans are all very different.
Brace yourself for shopping around. You may not feel like racing around to different stores if you’re ill, but one of the people talking about this on Twitter said that HEB grocery store pharmacies were out of stock, but CVS had it free.
A searchable treatment locator map from the Administration for Strategic Preparedness and Response is being re-worked at this site.
