Table 1. Open in new tab Description of...

Insurance Coverage

Pharmaceuticals

Vaccines

Commercial insurance

Prior approval request needed
Commercial insurance coverage varies depending on benefits plans and use: if drug is used at birth, it is more likely to be used in inpatient settings and to be covered by birth bundle packages; if drug is used after birth, it is more likely to be billed separately from well-child clinics
OOP payments for commercially insured patients reflect benefits variation across plans

No prior approval request needed
Covered in commercial insurance, with universal inclusion in benefits
No OOP payments for commercially insured patients

Public insurance

Prior approval request needed
Medicaid coverage more likely applies if the drug is used in outpatient settings but it may not be a requirement to cover it in inpatient settings
No OOP payments for Medicaid
Small OOP payments for CHIP

No prior approval request needed
Covered through Medicaid/CHIP
No OOP payments for Medicaid/CHIP beneficiaries

No insurance

Uninsured not covered

No prior approval request needed
Uninsured (and underinsured) infants covered through VFC

Table 1.

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Description of Insurance Coverage by Type of Technology

Insurance Coverage	Pharmaceuticals	Vaccines
Commercial insurance	Prior approval request needed Commercial insurance coverage varies depending on benefits plans and use: if drug is used at birth, it is more likely to be used in inpatient settings and to be covered by birth bundle packages; if drug is used after birth, it is more likely to be billed separately from well-child clinics OOP payments for commercially insured patients reflect benefits variation across plans	No prior approval request needed Covered in commercial insurance, with universal inclusion in benefits No OOP payments for commercially insured patients
Public insurance	Prior approval request needed Medicaid coverage more likely applies if the drug is used in outpatient settings but it may not be a requirement to cover it in inpatient settings No OOP payments for Medicaid Small OOP payments for CHIP	No prior approval request needed Covered through Medicaid/CHIP No OOP payments for Medicaid/CHIP beneficiaries
No insurance	Uninsured not covered	No prior approval request needed Uninsured (and underinsured) infants covered through VFC

Insurance Coverage	Pharmaceuticals	Vaccines
Commercial insurance	Prior approval request needed Commercial insurance coverage varies depending on benefits plans and use: if drug is used at birth, it is more likely to be used in inpatient settings and to be covered by birth bundle packages; if drug is used after birth, it is more likely to be billed separately from well-child clinics OOP payments for commercially insured patients reflect benefits variation across plans	No prior approval request needed Covered in commercial insurance, with universal inclusion in benefits No OOP payments for commercially insured patients
Public insurance	Prior approval request needed Medicaid coverage more likely applies if the drug is used in outpatient settings but it may not be a requirement to cover it in inpatient settings No OOP payments for Medicaid Small OOP payments for CHIP	No prior approval request needed Covered through Medicaid/CHIP No OOP payments for Medicaid/CHIP beneficiaries
No insurance	Uninsured not covered	No prior approval request needed Uninsured (and underinsured) infants covered through VFC

The VFC program provides vaccines at no cost to children who are Medicaid-eligible, uninsured, American Indian or Alaska Native, or underinsured and vaccinated at Federally Qualified Health Centers or Rural Health Clinics. Not all children covered through CHIP are eligible for VFC, only infants who are part of Medicaid expansion.

Abbreviations: CHIP, Children's Health Insurance Program; OOP, out of pocket payments; VFC, Vaccines for Children.

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