Coverage for Vaccines

STATE OF VERMONT DEPARTMENT OF FINANCIAL REGULATION 89 Main Street Montpelier, VT 05620-3101 For consumer assistance: [Banking] 888-568-4547 [Insurance] 800-964- 1784 [Securities] 877-550-3907 dfr.vermont.gov Insurance Bulletin #238 Coverage for Vaccines October 3, 2025 The purpose of this bulletin is to advise Vermont-regulated health plans as to the Department of Financial Regulation’s (DFR) expectations regarding coverage for vaccines. Under 8 V.S.A. § 4042(b)(4)(A)(ii), 33 V.S.A. § 1811(d)(5)(A)(ii) and 42 U.S.C. § 300gg- 13(a)(2), all health plans operating in Vermont are required to cover immunizations “that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention [ACIP] with respect to the individual involved.” On September 19, 2025, ACIP recommended that for individuals six months of age or older, “vaccination for COVID-19 be determined by individual decision-making [,]” including “an emphasis that the risk-benefit of vaccination in individuals under age 65 is most favorable for those who are at an increased risk for severe COVID-19. . .”1 Under 18 V.S.A. § 2, 18 V.S.A. § 126, and 26 V.S.A. Chapter 23, the Vermont Department of Health (VDH) has authority to issue health orders to, among other things, mitigate significant public health risks. VDH’s health orders are widely distributed, known to health care practitioners and pharmacists, and made publicly available to provide public health guidance to protect the health and wellness of Vermonters. On September 17, 2025, VDH used the authorities of 18 V.S.A. § 2, 18 V.S.A. § 126, and 26 V.S.A. Chapter 23 to issue a standing order authorizing qualified pharmacy personnel to administer the 2025-2026 COVID-19 vaccine to individuals ages 5 years and older. VDH also issued a health advisory notice to all Vermont health care providers and pharmacies broadly recommending respiratory virus vaccines, including vaccines to protect against COVID-19, influenza and respiratory syncytial virus (RSV).2 Based on guidance from the Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists (ACOG), the American Academy of Family Physicians (AAFP) and the Infectious Diseases Society of America (IDSA), VDH recommended vaccination against COVID- 19 for individuals six months of age or older who do not have a contraindication and identified certain groups who are at higher risk that should receive a COVID-19 vaccine. 1 See U.S. Dept of Health & Human Servs Press Release, ACIP Recommends COVID-19 Immunization Based on Individual Decision-making (Sep. 19, 2025). 2 See Vermont Dept of Health, Health Advisory, Updated Respiratory Virus Vaccine Guidance (Sep.18, 2025); Vermont Dept of Health, Standing Order for Administration of Vaccine, 2025-2026 COVID-19 Vaccine for Pharmacies, (Sep. 17, 2025). Docusign Envelope ID: E719CE38-1921-4B12-8C2E-5B699684072C VDH also recommended vaccination against RSV for older adults and infants and seasonal vaccination against influenza for individuals six months of age or older who do not have a contraindication. Because VDH’s vaccination guidance is consistent with and informs individual and shared clinical decision-making as recommended by ACIP, DFR expects Vermontregulated health plans to provide coverage for vaccines recommended by VDH and the cost to administer vaccines, without member cost-sharing and without utilization review for members who satisfy the recommended guidelines established by VDH for the provision of immunizations in Vermont. Plans are also expected to publicize how eligible members may access covered benefits for vaccines. Plans with prescription drug formularies may limit access to vaccines to those specified on their plan formularies, if there is at least one product on the plan formulary that will address each item on the VDH recommended guidelines for vaccines. Plans may require that vaccines be administered by a licensed health care provider under contract with the plan. 8 V.S.A. § 4067(b). DFR also encourages third-party administrators (TPAs) of employer-sponsored health plans to take steps aligned with this Bulletin. Employers should be made aware of the VDH recommended vaccination guidelines, and TPAs should encourage employers to voluntarily comply with this Bulletin. Inquiries about this Bulletin should be directed to Sebastian Arduengo, Director of Health Insurance Regulation. Kaj Samsom, Commissioner Date Docusign Envelope ID: E719CE38-1921-4B12-8C2E-5B699684072C 10/7/2025