The Private Payer Paradox of Access to Vaccine Coverage

Healthcare worker giving an injection to a patient

Many routine vaccines, particularly those for adults, are covered under group insurance drug plans with a healthcare professional’s (HCP’s) prescription. Under the National Drug Schedules (NDS) of the National Association of Pharmacy Regulatory Authorities (NAPRA) which aligned the provincial/territorial drug schedules in 1995 so that the conditions of sale for drugs is consistent across Canada, roughly 15 vaccines are classified a Schedule II drug[1]. The latter means that the drug must be retained within an area of the pharmacy where there is no public access, but do not require a prescription.

Schedule II vaccines should be good news for HCP’s, plan sponsors and more importantly plan members, saving appointments, time, and improving access and convenience. Instead, group insurers have ignored this classification and continue to require a prescription as a condition for reimbursement for all vaccines, even when the vaccine is categorized with other Schedule II drugs and no longer requires one.

Insurers continue to require prescriptions for all Schedule II routine vaccines that do not require one. Why?

There are no safety or abuse concerns as vaccines aren’t accessible to patients without an HCP being involved to sell it and administer it – who would abuse a vaccine in terms of “getting too many”? Additionally, as HCPs, pharmacists have the knowledge, skills and abilities to identify the patient’s need for a vaccine.

When insurers deny reimbursement for a Schedule II vaccine due to an extraneous prescription requirement, it creates inequities and an unfair barrier to access among plan members living in different provinces and territories. This is because in some of those regions, pharmacists have vaccine prescribing authority within their scope of practice. In regions where they don’t, an insurer’s requirement for a prescription adds costs to our healthcare system because of extra, avoidable appointments with a physician who could use their valuable time for patients with a greater need. If plan members choose not to take time away from work to visit their physician simply for a vaccine prescription, they will incur an out-of-pocket expense for their vaccine.

The perfect Ontario storm – a gap in vaccine access mixed with a growing gap in access to family physicians.

Ontario is one of the three remaining provinces where vaccine prescribing authority regulations lag[2]. Although the provincial regulations recognize NAPRA’s Schedule II vaccines allowing Ontario pharmacists to administer vaccines listed in Schedule II without a prescription[3], insurers still won’t automatically reimburse vaccines covered by their group plan sponsors without a prescription.

This unnecessary and additional burden on physician’s should be carefully considered because of the serious and growing gap in access to family physicians. The Ontario College of Family Physicians predicted as recently as November 2023 that more than four million Ontarians will be without a family doctor by 2026. The data indicates a worsening crisis in the ability of improve patients’ access to care[4]:

  • 8 million Ontarians were without a family doctor in March 2020 and nearly 2.3 million in September 2022, ‘Roughly the combined populations of London, Thunder Bay, Ottawa, Hamilton and Kingston without access to comprehensive preventative care.’ According to the Ontario Medical Association.
  • Nearly 65% of family physicians reported that they are planning to change or leave their practice according to a survey of family doctors by the College.

The College also reported that family doctors are spending too much time on unnecessary administration and do not have the support to manage our aging and complex population. The Ontario Medical Association quantified the 2023 administrative burden on physicians in Ontario as equivalent to 20.6 million patient visits per year based on an average of 20 minutes per visit. Physician administration includes requirements from plan sponsors and insurers, including sick notes and referrals for paramedical services, which ‘do not contribute to patient care and well-being [but] slow down access and discourage patients from staying home when sick[5].’ The ‘burden’ includes the requirement for a prescription for reimbursement of routine vaccines when no prescription should be required.

The insurance industry is keenly aware of the administrative burden placed on physicians by insurers. In 2023 The Canadian Life and Health Insurance Association (CLHIA) began working with its member companies to identify ways to reduce the insurance industry’s role in physicians’ administration burden[6].

Unlike Ontario, Quebec is a province where pharmacists can fill an insurer’s requirement for a prescription for Schedule II vaccines. Even without this additional prescribing burden physicians in Quebec have also spoken out against the time required to complete paperwork for insurance companies. In March 2024 CBC News reported that family doctors say [it] takes away from the time they spend caring for patients. Pascal Renaud, president of the Association des Médecins Omnipraticiens de Québec (AMOQ), says “It’s two hours a day of work, all the paperwork.” Many of the requests are for referrals for paramedical services as a requirement of reimbursement[7].

The time is now to knock down vaccine barriers for plan members from coast-to-coast.

Vaccines play an important role in disease prevention, reducing the burden on public healthcare systems, individuals, and in the workplace, but they can only deliver if people receive them. Vaccines that are eligible under group plans are too often ineligible for some plan members except with an HCP’s prescription. With no potential for abuse of vaccine coverage or erroneous claims, and only positive health outcomes, plan sponsors and advisors should be demanding that insurers remove the prescription requirement for routine vaccines that are included in Schedule II Drugs across the country to ensure fair and appropriate access to plan members and their families. Without this change, barriers to accessing valuable vaccines will continue.