Last month, the New Jersey Department of Banking and Insurance issued guidance directed at health insurers regarding coverage of COVID-19 vaccines. The bulletin “strongly encourages” insurers to continue coverage of the vaccine without cost-sharing and without a prescription for all individuals ages 6 months and older.
The bulletin was issued amid a gap in guidance from federal regulators. This season's COVID-19 vaccines were approved by the Food and Drug Administration (FDA) in August, but with new restrictions on eligibility. For the first time, the updated shots are approved only for those ages 65 and older or at high risk of severe illness. Historically, the Centers for Disease Control (CDC) has issued guidance on administering the vaccines within days of its approval by the FDA. The CDC 2024-2025 COVID shot was recommended by the CDC for “most adults ages 18 and older.” However, guidance for this year's booster has yet to be published. The lack of guidance from the CDC leaves the issue of how exactly the shots will be covered by insurance plans in limbo.
The bulletin calls on insurers to update plan documents and clearly communicate how participants can access covered benefits for vaccines. However, the bulletin stops short of issuing a coverage mandate.
Group health plan sponsors with policies issued in New Jersey should contact their insurer to learn how the 2025-2026 COVID-19 shot will be covered by their policy — including whether there will be any out-of-pocket cost, whether a doctor's office visit or a prescription will be required, and whether there are any age or other eligibility restrictions associated with the vaccine's coverage.
Read the guidance here: NJDOBI | NJ Department of Banking and Insurance Issues Guidance on Coverage of COVID-19 Vaccines