Content starts here
CLOSE ×

Search

Reply
Contributor

Will Medicare Pay for Shingrix?

Will Medicare pay for the new Shingles Shot---Shingrix?

62,071 Views
72
Report
Periodic Contributor

I registered with Salt Lake County Health Department on the first part of October for the Shingrix vaccine.  In my area, it will be at least 2 to 8 months until Utah gets more vaccine according to the pharmacies I spoke with.  None would even let me sign up.  So, I registered with Salt Lake County Health Department on the first part of October for the Shingrix.  They called me the first week of November to make an appt. with me to get the shot.  When I arrived I was told that they could not bill medicare for anything besides flue and pneumonia vaccines.   I asked them to hold my shot until I could get more info from United Health Care.  I called customer service and after getting the runaround from a couple of agents, I called back.  This time I got Samantha.  She got me some answers.  She emailed a  from OPTUM Rx MAPD Reimbursement Request form.  She said I would have a copay depending whether my prescription deductible had been met.  I got my shot and a receipt for my Payment in full of $154 to Salt Lake County Health Department and added my name to the list of 101 people for the follow up shot.  I then went to my pharmacist who would not previously add me to the waiting list.  I found out that if I had gotten my shot, there, my copay would have been approximately $60.  I had decided I would get this shot and pay it myself if I had to.  So, now I will potentially be reimbutsed by UHC for $94.  I am glad I decided to spend the time investigating.

0 Kudos
31,138 Views
0
Report
Periodic Contributor

I went to the pharmacy on Tuesday & was told that the co-pay would be $167. This was at CVS. The young woman tried using all of my coverages and looked for discounts, but couldn't find any. Try Goodrx.com to find a discount. The best price I saw with a coupon was $150.37 @ Costco without using your Medicare. I am going to check the Medicare website as well to see if she missed something. 

0 Kudos
19,629 Views
2
Report
Periodic Contributor

Ask your Part D plan. Neither Your Pharmacy, nor Your doctor, nor the Medicare website can give you specifics on your Part D coverage!

0 Kudos
19,455 Views
1
Report
Periodic Contributor

My Part D plan should be on my CVS account & that co-pay might be the tier that I located in the Formulary. But a good question to ask. My Aetna Part D coverage does indicate it is covered. 

 

My daughter & son-in-law are covered under the ACA, they were given the vaccine with no co-pay. 

0 Kudos
25,288 Views
0
Report
Honored Social Butterfly


@SaraR650827 wrote:

LeslieCY hit the nail on the head with Part B, but for Shingrix, specifically, I found Medicare to be so confusing as many plans do not cover this particular brand BUT will cover the competitor such as Zostavax.

 


One of the side effects of Zostavax is SHINGLES, the very same thing you hoped it would prevent!

 

Additional Side Effects Reported With ZOSTAVAX Are:

  •  Allergic reactions that may be serious and may include difficulty in breathing or swallowing. If you have an allergic reaction, call your doctor right away.
  •  Chickenpox
  •  Fever
  •  Hives at the injection site
  •  Joint pain
  •  Muscle pain
  •  Nausea
  •  Rash
  •  Rash at the injection site
  •  Shingles
  •  Swollen glands near the injection site (may last a few days to a few weeks)

https://www.zostavax.com/about/shingles-vaccine-side-effects/

 

I was a victim of Zostavax!

20,391 Views
0
Report
Honored Social Butterfly


@jimarleywrote:

Will Medicare pay for the new Shingles Shot---Shingrix?


As with the old one - it should be covered by your Medicare Part D plan, NOT Part B.

GoodRx gives an estimate of the cost depending upon which stage a person might be in in their Part D coverage and which plan/insurer they have. 

GoodRx - Shingrix Medicare Coverage

 

 

It's Always Something . . . . Roseanna Roseannadanna
26,012 Views
6
Report
Contributor

I think it should be covered along with other important immunizations in Medicare Part B.  We have Humana Part d and the cost is going to be $320 to receive both shots.  I don’t know how many people will be able to afford this.  In the end, the cost of immunizing people against shingles will be less for Medicare if it is covered. 

24,748 Views
5
Report
Honored Social Butterfly


@BarbaraShearer52wrote:

I think it should be covered along with other important immunizations in Medicare Part B.  We have Humana Part d and the cost is going to be $320 to receive both shots.  I don’t know how many people will be able to afford this.  In the end, the cost of immunizing people against shingles will be less for Medicare if it is covered. 


We may all want it to be covered by Part B but in order to keep down cost associated with Part B, it isn't.  Of course, those eligible low income seniors may get extra help for Medicare Part D.

 

Part B Medicare is paid for by premium payments from beneficiaries which represents about 25% of the programs cost, the other 75% of the cost of Part B Medicare is paid for out of taxpayers money from the General Fund.

 

The ONLY preventative care vaccines or immunizations covered by Medicare Part B are:

1.  Influenza: once per flu season 
2.  Pneumococcal: once per lifetime with high-risk booster after 5 years - covers both types of vaccines to cover as many varieties as possible
3.  Hepatitis B: for persons at intermediate- to high-risk

4.  TDaP  

 

These are the ones which have coverage when given in a doctor's office.

The others are covered by Medicare Part D and for coverage are given by a state licensed pharmacist.

 

Yes, this is done this way in order to save the government money one way or another - and Part B premium cost for beneficiaries.

 

In the overall coverage length, this is not an expensive vaccine especially since it doesn't have to be given every year.

 

Extra Help with Part D Medicare is available for those  beneficiaries with low income.

 

 

It's Always Something . . . . Roseanna Roseannadanna
0 Kudos
25,432 Views
4
Report
Periodic Contributor

GaiL1 has given some slightly incorrect information about Medicare Part B coverage of vaccines, so I am compelled to respond:

  1. Yes, annual flu shots are covered
  2. Yes, pneumonia vaccine is covered but not "once per lifetime" and there is no "booster" after 5 years.  For many years the coverage was only for Pneumovax 23 valent).  But several years ago the CDC/ACIP also recommended Prevnar13.  That is not a booster. It's another vaccine against pneumonia.  The current recommendation is to get Prevar13 first followed by Pnemovax23 after 6 mos - year.  But many people already had the Pneumovax so they just need the Prevnar13 to complete the recommended doses.
  3. Hep B is only covered for people at "medium to high risk" per CDC guidelines.  So perhaps GaiL1 met those criteria, but most people do not.
  4. TDaP is not covered under Part B except and unless the patient has had specific exposure such as a cut, open wound, skin puncture.  Othewise, this is only covered under Part D. TDaP is a combo vaccine for Tetanus,  Diptheria and Pertussus (aka Whooping Cough).  It is recommended for adults every 10 years.  So if they get a cut, for example, within that 10 years and their doctor has documentation TDaP was already given, he/she would like just give a Tetanus booster which is Td.  It is Tetanus that is the specific risk from a cut.  We have had some areas of petussus/whooping cough epidemics recently.  Babies are particularly at risk.  So grandparents are particularly adivsed to be sure to have TDaP before holding their grandbabies.  BUT, that purpose is just covered under Part D.

Preventive services under Part B come with $0 copay.  But under Part D you may have a deductible to meet first or might be in your coverage gap, or the vaccine on a high tier in your Part D plan so in spite of it being "covered" your share of cost could be sizable, nonetheless.

 

Other's in this thread have also stated, incorrectly, that the shingles vaccine was "moved" from Part B to Part D.  Also incorrect.  Those of us who are old enough or in the health insurance business like me will remember that Original Medicare (created in 1965) never covered preventive care at all and also never covered prescription drugs (pills or self-administerd injections).  They added a few things to coverage later, such as anti-cancer pills, but not until the Part D law was passed in 2006 was there any meaningful coverage for prescription drugs except therapeutic injections that much be administered in the doctors' office.  Years after that Congress approved the addition of certain other preventive services, such as the Annual Wellness Exam.   But, they never at no time covered more that what they cover today as vaccines under Part B.

21,853 Views
0
Report
Newbie

I too thought it should be covered by Medicare, but found out otherwise.  However, my cost is only $80 for both shots under my UPMC health plan, so there's obviously a wide variance in how much you're charged.

27,756 Views
2
Report
Newbie

You need to check with your individual Part D carrier.

The Humana plan considers Shingrix as Tier 4 shot

and the out of pocket is quite high.  Yes, it is covered

by Medicare, but, what do you have to pay? Articles

are misleading that say "Covered by Medicare Part D"

Check first before having the shot at a participating

pharmacy.  Don't go to your doctor to have it done. 

My understanding is that it has to be a participating

pharmacy for Part D coverage.    

0 Kudos
27,409 Views
1
Report
Honored Social Butterfly


@JamesR885384 wrote:

You need to check with your individual Part D carrier.

The Humana plan considers Shingrix as Tier 4 shot

and the out of pocket is quite high.  Yes, it is covered

by Medicare, but, what do you have to pay? Articles

are misleading that say "Covered by Medicare Part D"

Check first before having the shot at a participating

pharmacy.  Don't go to your doctor to have it done. 

My understanding is that it has to be a participating

pharmacy for Part D coverage.    


Beneficiaries can change their Part D plans yearly during open enrollment.  The reason for this is that our medications might change and the purpose in picking the best plan for oneself is based on the medications one is currently taking or, in this case, plan to take.  

 

If a beneficiary wants this shingles vaccine and it runs costly under their current plan which is in place, they can review the options during the next open enrollment by including it in the analysis for the best plan for the beneficiary.  However, it is important to include all cost in this analysis based on the medications which one takes or plans to take - premiums, deductibles, copays, tier assignment and associated cost to the beneficiary, where and how you can get the meds.

 

Most states regulate who can give a vaccine in a pharmacy location because storage, prep and where and how to give certain vaccines is sometimes very important - so just make sure that the (whatever) insured approved pharmacy has such an approved person and when they are available for this procedure.

 

 

It's Always Something . . . . Roseanna Roseannadanna
30,365 Views
0
Report
Social Butterfly

24,576 Views
0
Report
cancel
Showing results for 
Show  only  | Search instead for 
Did you mean: 
Users
Need to Know

NEW: AARP Games Tournament Tuesdays! This week, achieve a top score in Atari Centipede® and you could win $100! Learn More.

AARP Games Tournament Tuesdays

More From AARP