Does Medicare Cover Paxlovid in 2024?

In May 2023, the U.S. government announced the official end of the public health emergency caused by the COVID-19 pandemic. However, you can still catch the virus, and it’s just as important as ever to take precautions when you get sick.  

The U.S. Centers for Disease Control and Prevention (CDC) currently recommends isolating yourself until at least 24 hours after you no longer have a fever and have begun to feel better. If you’re at risk for serious health consequences, you should also seek treatment from a healthcare provider.  

Antiviral medications like Paxlovid may help you avoid the worst symptoms and recover sooner. If you’re over 65, it’s especially important to know about your COVID-19 treatment options and how they’ll be covered under Original Medicare or a Medicare Advantage plan.  

Who’s at Risk for Severe COVID? 

While COVID-19 often only causes mild illness, especially in people who have been vaccinated and received the recommended booster shots. the virus can have severe effects. Some patients struggle to breathe, need to be hospitalized, or even die.  

According to the CDC, age is the biggest risk factor for these dangers. People between the ages of 65 and 74 are 60 times more likely to die from health issues caused by COVID than people between 18 and 29. If you’re between 75 and 84 years old, you’re 140 times more likely to pass away because of the virus than a young adult under 30. 

The chances of serious consequences are also worse for people who already live with chronic conditions like: 

• Asthma 
• Cancer 
• COPD 
• Heart disease 
• Kidney disease 
• Obesity 

If you’re at high risk for serious illness due to your age or chronic conditions, you should see a healthcare provider as soon as possible after you start to feel symptoms. Acting fast could make a huge difference in your outcomes. 

Antiviral Treatments for COVID-19 

An antiviral is a type of drug that helps your body recover from viral infections. For example, people with the flu are commonly given the medication that’s sold under the name Tamiflu (oseltamivir phosphate) to reduce their symptoms and shorten their illness by about a day. 

There are three antivirals currently authorized by the U.S. Food and Drug Administration (FDA) to treat COVID-19. They work by stopping the virus from duplicating itself in your body. Each of these drugs is intended for people who are at high risk for severe disease and who have mild or moderate symptoms: 

• Paxlovid, which combines two drugs called nirmatrelvir and ritonavir, is the medication that healthcare professionals prefer to use in most situations. Taken as a pill, Paxlovid received full FDA authorization for adults and for children who are at least 12 years old. Evidence shows it greatly reduces the chances that people with COVID will need to be hospitalized or die if they start treatment within five days of developing symptoms.
• Molnupiravir, marketed under the name Lagevrio, is another oral antiviral taken in pill form. Research has found it helps some people but is much less reliable than Paxlovid. It’s not considered safe for children under 18. Doctors will only prescribe this drug when another treatment option isn’t available or appropriate for a specific patient.
• Remdesevir, marketed as Veklury, is administered intravenously, meaning through an IV or a drip. It’s a highly effective treatment that has been authorized even for children under 12. However, it’s not prescribed as often as the oral antiviral alternatives because it takes more time and resources to administer. Outpatient treatment with remdesivir requires three infusion sessions that each last between one and two hours.

Monoclonal Antibodies for COVID-19 

Antiviral drugs are different from monoclonal antibodies, which are a type of molecule produced in a laboratory that can be designed to respond to various threats like cancer, auto-immune disorders, or a virus. Monoclonal antibodies were used to treat COVID earlier in the pandemic. However, these products weren’t effective against the omicron variants that became the most common forms by late 2021, so the FDA ended their emergency-use authorizations.  

In 2024, however, the FDA issued a new authorization for a monoclonal antibody called pemibivart, marketed as Pemgarda. Given as an intravenous infusion, this treatment is for people who are over 12 years old and have compromised immune systems that don’t react strongly to vaccination or boosters. This drug increases the levels of antibodies that fight COVID and lowers the risk of infection. It is not used as a treatment after someone is infected. 

Medicare and COVID-19 Antivirals 

The U.S. government stopped distributing free antiviral drugs to fight COVID-19 in late 2023. These medications are now available commercially, so patients need to understand how they will get insurance coverage for their treatment. 

Until the end of 2024, you can access a supply of Paxlovid for free by signing up for a patient assistance program and going to a participating pharmacy. If you’re insured by Medicare or Medicaid or even if you’re uninsured, you can enroll in the manufacturer’s patient portal to get your medication for no charge. People on commercial insurance, such as the coverage provided by an employer, may be reimbursed for their copay. 

If you’re enrolled in Original Medicare (Parts A and B) through the federal government, you need a Medicare Part D prescription drug plan from a private insurance carrier to get help paying for most medications. Based on what Part D plan you choose, your costs will likely include a monthly premium, an annual deductible you must meet before insurance starts to pay, and a copay when you pick up a prescription. Many Medicare Advantage plans, which are offered by private insurers to substitute for Original Medicare, include Part D coverage. 

The Centers for Medicare and Medicaid Services (CMS), the government agency that administers these health insurance programs, has encouraged all Part D plans to cover at least one oral antiviral with a $0 copay. You should check with your plan to find out exactly how much you’ll pay for treatment. 

If a doctor determines that it’s medically necessary for you to receive monoclonal antibodies, this treatment can be covered in full by Medicare Part B, the part that provides medical insurance. You’ll pay nothing when you go to a provider who accepts assignment, which means they take the Medicare-recommended amount as full payment. A Medicare Advantage plan must match Original Medicare’s hospital and medical coverage. However, you may have to see a doctor in your plan’s provider network to take full advantage of your benefits. 

While the pandemic era may be officially over, COVID-19 remains a threat, especially for people at high risk for severe symptoms. By getting to know your coverage and treatment options, you’ll know how to access potentially life-saving help if you get sick. 

About GoHealth 

GoHealth is a leading health insurance marketplace and Medicare-focused digital health company. Enrolling in a health insurance plan can be confusing for customers, and the seemingly small differences between plans can lead to significant out-of-pocket costs or lack of access to critical medicines and even providers. GoHealth combines cutting-edge technology, data science, and deep industry expertise to build trusted relationships with consumers and match them with the healthcare policy and carrier that is right for them. Since its inception, GoHealth has enrolled millions of people in Medicare plans and individual and family plans. For more information, visit GoHealth.com.