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Re: Will Medicare Pay for Shingrix?

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Message 1 of 27

Saying or being told a particular medication is "covered", Shingrix in this case, is a meaningless term for almost all insured claims.

 

All 2019 PDP's in my state show Shingrix is "covered". The average retail is in the $150 range. Some plans show the drug as a tier 3 with a copay, others have it as tier 4 with coinsurance.

 

Member cost will vary by plan, pharmacy, zip, deductible, etc.

 

When you are told a medication, test or procedure is "covered" you should press further to determine your actual OOP cost. 

 

Many times a prescription drug can have a lower cash price (including discounts from places like GoodRx) than your plan copay. It could be advantageous to carve out the drugs with higher retail pricing when comparing drug plans. Not only is it possible to save $$ on the copay but the resulting comparison could generate a lower premium plan as well.

 

It has been my experience that often the higher priced PDP's have inflated retail prices and similarly inflated copay's on some generics. By the same token a plan with a deductible will more often than not result in lower total OOP.

 

YMMV


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Re: Will Medicare Pay for Shingrix?

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So much mis-information on this thread!   First, the statement that the Part D copay is $150 per shot could not possibly be correct.  For one thing, $150 per shot.  The manufacturer, GSK, sells the vaccine for $140 per shot.  This would be tantamount to a 100% coinsurance which is non-sensical.  What is more likely is that there was a deductible involved in the plan, meaning the plan pays nothing until the annual deductible is satisfied.  The end result may mean your plan pays $0 for this "covered" drug but there is a big difference beween a copay/coinsurance and a deductible.  My husband's Humana Part D plan, for example as a $415 annual deductible.  So they would pay nothing if he has not yet met his deductible.  However, what he pays out of pocket would credit (accumulate) toward satisfaction of his deductible.  Any copays or coinsurance paid do not credit toward anything.  Once he has satisfied the deductible, his particular plan rates Shingrix as a "Tier 4) drug with a 34% coinsurance.  Your plan will likely be different.  This is just to illustrate the difference between deductibles and copays. (note a copay is a fixed dollar amount.  A coinsurance is a percentage of the drug cost.  Either way, these are the patient's cost share)

 

Second, are different types of Part D plans, some with or without deductibles and also differences in the coverage tiers (what you pay, depending upon the tier it falls under in your specific plan).  So to make a flat statement about the copay for everyone's plan is not possible.  

 

Third - Each part D plan must cover at least one of every CDC recommended vaccine (even travel vaccines) that are not otherwise covered by Part B of Medicare (Part B covers only flu shots, both pnemonia vaccines (23 valent and 13 valent) plus Hep A for those considered medium to high risk)  Even though word is now out that Shingrix is superior to Zostavax (as stated by the CDC) CDC has not taken Zostavax off their list as a shingles vaccine.  This could enable a sneaky Part D plan to include Zostavax, but not Shingrix, on their formulary to satisfy coverage of a shingles vaccine.  But, that would indeed be a very poor plan and one you should leave.  The way to know is to call your plan to ask 1) is Shingrix on their formulary, 2) what is my deductible, if any, and have I satisfied it for 2019 and 3) what is my coinsurance % once I meet my decutible.

 

Also, many complaints that the vaccine is not free because it is preventive.  Medicare Part B and the Affordable Care Act (which governs commercial plans) make preventive care services with $0 copays.  But the Medicare Part D program is an entirely different animal.  It was passed in 2006 under the Bush administration with much rancor in congress by Republicans who generally don't like spending federal money on health benefits.  Bush was soundly criticized by conservatives.   The only way to "sell" the legislation was to put some limits on cost which is why many plans have deductibles and copays/coinsurance.  Let's face it, most prescription drug benefits ar for drugs, not vaccines.  It's weird enough that a presciption drug plan would include vaccines.  That, too was hotly debated during the enactment of the legislation.  But, the point was that Congress ultimately decided not to expand its obligations too much under Medicare.  The Part D program is based on the generic benefit design and negotiated contracts with the private Part D plans who assume the risk for costs as long as they meet minimum Medicare Coverage requirements.   Since Original Medicare, as passed in 1965, didn't cover drugs outside of the doctors office and didn't cover any preventive care, we have come forward considerably since then, though not to everyone's satisfaction.

 

Remember, for questions about Medicare Part D, contract your Part D carrier.  Your pharmacy and your physician, especially, are not compentent to explain your coverage, including why the plan covered $0 for your Shingrix vaccine.  Generally, people on Medicare should not be getting Shingrix from their doctor anyway since the Part D plan cannot reimburse physicians.  Try to find a plan-contracted retail pharmacy for this.

 

Oh yes, on top of everything else, there is a serious shortage in supply of Shingrix right now.  CDC predicts this will be so until at least June.  Try to get on a waiting list.

 

 

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Re: Will Medicare Pay for Shingrix?

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Well, yes, Part D plans are required to "cover" Shingrix. But, the copay for each of the two injections averages $150 (i.e., about $300 total) for the "covered" Shingrix vaccine. Of course, Medicare covers the huge hospital bill, if needed, if I get shingles and need hospitalization(can easily be thousands and thousands of dollars). I don't consider a $300 cost as "coverage." What's that saying about "an ounce of prevention is worth a pound of cure"?

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Re: Will Medicare Pay for Shingrix?

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In September 2018, The waiting lists at pharmacies was so long, no one would even put me on the waiting list for Shingrex.  I called the local Salt Lake County Health Department and they said I could sign up and they would call me on October 1, 2018 to set an appointment to get the shot.  When I arrived, they said they were not set up to deal with Medicare.  I decided to pay the $154 for the first shot and signed up for the second.  I have Uniited Health Care/AARP.  I submitted my receipt and the forms Optum sent me (their contracted processor).  I received a check from them in about one week for $102.00 reimbursement.  I can't speak for every Medadvantage plan, but United Health Care covered it less my deductable. 

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Re: Will Medicare Pay for Shingrix?

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@michaele325563 wrote:

This is a totally rediculous situation. Everyone says focus on "Preventive Care". Medicare encourages you to shop for coverage, but nowhere, on their website or any other website can you simply find out which Part D plan covers the new shingles vaccine. Shouldn't that be a simple question?


For 2019, the majority of Part D plans should cover both shingles vaccines - with the newest, Shingrix,  being the best option.  

 

Shingrix should be be on their formulary - but if not, Medicare needs to know about it because they are suppose to cover (with a co-pay) all vaccines not covered by Medicare Part B.

 

Shingrix is a (2) part vaccine - with 2 - 6 months in between.  It is more effective than the old one - Zostavax.  It is recommended by the CDC for most everybody to get Shingrix even if you have Zostavax before.

 

As always, your primary care doctor should tell you if there is some reason for you not to get it.

 

Medicare Q1 FAQ - Do Medicare PartmD plans cover the shingles vaccine?

 

Just put it in the formulary search with any other meds you might take on a regular basis and see which plans come up with the best cost for you all the way around unless you have some other criteria to add to the mix in decision making.

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Re: Will Medicare Pay for Shingrix?

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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.

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Re: Will Medicare Pay for Shingrix?

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This is a totally rediculous situation. Everyone says focus on "Preventive Care". Medicare encourages you to shop for coverage, but nowhere, on their website or any other website can you simply find out which Part D plan covers the new shingles vaccine. Shouldn't that be a simple question?

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Re: Will Medicare Pay for Shingrix?

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Message 8 of 27

Alas, both the 2018 & 2019 formularies were paper versions. Try calling United Healthcare they may be able to help you. I am in CA the formulary might be different in Utah. 

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Re: Will Medicare Pay for Shingrix?

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Will you give me the  link to your 2019 formulary?  I have United Health Care (AARP) and have been searchng for their 2019 formulary.  Utah has huge waiting lists and you cannot get added to them at this point.  The health department here has it in stock for $154 for each shot.  Like you, I had the original shot when it came out around 5 years ago.  It was not covered, but Utah State government had a deal where if the shot was not cmpletely covered by insurance, and if you were over 60, you could get it at local pharmies for $20.  I would appreciate your help.  No one at the pharmacy or health department has any decent info.  Thanks

 

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Re: Will Medicare Pay for Shingrix?

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Message 10 of 27

Super!

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