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Re: Will Medicare Pay for Shingrix?

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Message 1 of 37

I have United Healthcare Medadvantage Complete.  I got on a waiting list a Salt Lake County Health Care in September 2018.  They called me on October 2, 2018 to say they had my vaccine.  I had to pay the full amount of $152 and submit a reimbursement to United Health Care.  I received my check less my copay for about $102 a week later.  I signed up for the second shot on October 2, 2018.  In June 2019 I got a call to come in an get the shot.  Again, I paid in full and submitted a reimbursement to United Health Care.  I received a reimbursement very quickly less my $50 copay.  A week after that, I received a call from two pharmacies where I was on a waiting list to see if I wanted to get my first shot.  I told them I had already had both shots.  My answer is....my Medicare is handled by United Health Care AARP.  I was reimbursed less my copay.  I can't speak for ay other types of coverage.  I hope this is helpful.

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Re: Will Medicare Pay for Shingrix?

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Message 2 of 37

@LeslieCY I have over 45 years working in the health insurance business. I know what a copay is, and how insurance works.

 

You are entitled to BELIEVE your answers were correct if you want . . . but you are not entitled to change the truth about how insurance plans work.

 

There are quite a few insurance agents who likewise do not understand the way Part D deductibles work.

 

I made a video that specifically addresses that problem. It is one of my more popular ones.

 

 


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Re: Will Medicare Pay for Shingrix?

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Message 3 of 37

Yes, I absoluterly agree with all you say. Good Rx is pretty good for some drugs.  Little help on Singrix. And as you, my Part D wants about $300 for total 2 doses Shingrix. So so with WellRx. Even BlinkHealth on occasion for drugs. Had good coverage for one by Agility (?-I can check if interested). I have no consistently found any of the other drug alternatives helpful. 

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Re: Will Medicare Pay for Shingrix?

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Message 4 of 37

To answer Gail1's questions:

 

PPACA (also known as the ACA and also as Obamacare) DID add many preventive care benefits to Medicare.  It just didn't add any new vaccines to Part B coverage.  The Medicare Part D drug coverage was added by Congress in 2006.  Before that, Medicare didn't cover outpatient prescription drugs as all! (a few exceptions for cancer, transplants).  With Part D's passage additional vaccines became covered but only under drug plans because Part D funding and administration is totally separate from Medicare Parts A/B.   While Part D is a cost to the federal government, the government limits its exposure by offering this only through drug insurance plans who assume the financial risk by offering Part D coverage, (i.e. the government transfers the financial responsibility to the plans).

 

But the ACA (passed in 2010) did set into motion a 10 year step by step reduction in cost to beneficiaries for drugs under the Part D "coverage gap" or "donut hole" such that it will be gone by 2020.

 

As to vaccines, original Medicare Part A and Part B medical coverage,  as passed in 1965 also didn't cover ANY preventive care and that meant neither did it cover vaccines.  This was a program originall intended to treat illness and injury only.  Little by little over the years some were added such that Part B now covers Flu Shots, pneumonia vaccines and Hep B (with limitations on Hep B).   So your impression that Medicare is one by one moving vaccine coverage from Part B to Part D is not correct.  Zostavax and Shingles were never covered on Part B.   TdaP is only covered on Part B if you have a cut or open wound because that would be treating an injury (i.e. theoretical exposure to tetanus).  They will also cover Td which is a tetanus booster.  But normally, TDap is only covered under Part D.  This was not a move from B to D.

 

As to Shingrix and my husband's plan, yes this vaccine is on the Humana formulary.  Yes, it cost him $151 for the first dose purchased at a plan-contracted pharmacy.  That did not include the $50 administration fee his doctor charged because that pharmacy couldn'tadminister it (administration fee is also under Part D). We will submit a claim for that part which will also hit his deductible. The Pharmacy filed with the plan and the EOB clearly says the $151 was "applied to his deductible" - if he gets the second dose just before the end of this year, it will be covered (because he will have met his deductible by then) but it's on Tier 4 of his plan so he will still have a 34% coinsurance to pay.  Better that than to get shingles!!

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Re: Will Medicare Pay for Shingrix?

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Message 5 of 37

 Somarco quoted me on several points and then claimed my information to be "wrong" while proceeding to provide misinformation himself.  I work in healthcare management and health insurance administration, for about 35 years now.  I'm trying to be helpful to my fellow AARP members because this topic is confusing.  Even the primary care physicians I manage are confused.  So no wonder this is hard on our members.

 

I said:  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.

Somarco responded with: Maybe non-sensical but it happens. Quite often I also see generic copays that are higher than cash prices. But it happens, and quite often.

 

My clarification:  A "copay" refers to a fixed dollar amount (such as $5, $10) that is the patient's share of cost once a deductible is met.  It is possible that the deductible is satisfied and the plan applies a copay of, let's say, $10 but the actual cost of the drug to the plan is only $7.00. By rights, the member's cost share should therefore only be $7.00.  But, this is a practice by Pharmacy Benefit Managers (PBMs) that is being highly criticized, as it should be, so write your congressman.  But I was referring to a "coinsurance" which it a percentage of the drug cost paid by the patient (once the deductible is met).   A coinsurance cannot be above 100% of the health plan's allowed cost for the drug since it is, by definition, to be multipled by the cost allowance.  Is it possible that one could pay cash for a drug and pay less than the copay?  Yes. But, highly unlikely with Shingrix (a vaccine, not technically a drug) because most plans use coinsurance for vaccines.  As you all know there are multiple Tiers in most drug plans.  For example, my husband's Humana plan has this for a 30 day supply.  Notice that Tiers 1 and 2 have copays and the others are coinsurance.  Shingrix falls under Tier 4.

Tier 1: Preferred Generic $0, Tier 2: Generic $1 Tier 3: Preferred Brand 25%,  Tier 4: Non-Preferred Drug 34%, Tier 5: Specialty Tier 25%

Ironically, there are two vaccines for shingles. CDC says Shingrix is preferred over Zostavax, but because there are two, Humana can play the game of calling this on non-preferred (their own definition).

 

I said:  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

Somarco responded with:  Again, wrong . . .Drugs covered still have a copay until the deductible is satisfied. With many plans the deductible does not apply to tier 1 or 2 drugs, especially if using a preferred pharmacy.

 

My clarification:  A deductible is defined as the first dollars cost each year that is NOT covered by the plan. 25% What you pay, therefore, is just the uncovered cost.  That is not a copay.  Copays and coinsurance only kick in once the annual deductible is satisfied.m  Is it possible that the deductible might be waived (or not apply) to certain drug "Tiers" or be waived for certain "maintainence drugs".   Sure, but when a deductible does apply, a copay doesn't until the deductble is consumed.

I said:  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.

Also wrong, for reasons already stated.

 

My clarification: Again, you are confusing the "cost to the patient" with the term "copay" or "coinsurance"

I said:  the Affordable Care Act (which governs commercial plans) make preventive care services with $0 copays.

Somarco responded: Obamacare does not make preventive DRUGS free, only the professional services that meet preventive care criteria.

 

My clarification:  Wrong!  First, vaccines are not drugs even though Congress has confused the matter by covering certain vaccines for Medicare beneficiares under their Part D drug plans.  Second, Obamacare does require that all recommended vaccines be covered on non-granfathered commercial medical benefit plans (not Medicare) with no share of cost.  No deductible, copay or coinsurance.  On commercial plans, covered vaccines are "medical" benefits; not part of the prescription drug plan.  "Recommended vaccines" are found on the CDC website under the Advisory Committee on Immunization Practices (ACIP). 

 

I said: 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.

Somarco responded: Very few pharmacy's are set up to file Part B claims. 

 

My clarification: I said nothing about retail pharmacies giving vaccines that are covered by Medicare Part B nor by commercial medical benefits. I was only referring to Shingrix which is a Part D (not B) vaccine which is admintered by the PBMs (defined above).  PBMs cannot process a medical claim for this submitted by a doctor because a) its not a drug plan benefit and b) they are not set up to handle medical claims (the claim is a CMS 1500 used by doctors to bill Medicare and insurance plans).   If your doctor gives Shingrix to a Medicare beneficiary (who does not otherwise have commercial coverage as primary) your doctor cannot bill for this.  You will pay your doctor's usual fee for the vaccine plus administration of the vaccine, have to get a receipt and file a claim with your Part D plan. 

somarco added:  Just ask insulin dependent diabetics that have a pump how hard it is to find a pharmacy that can/will fill their insulin and file under Part B . . .

My clarification: As noted above, I was talking about a Part D vaccine, not a Part B covered item.  I do sympathize with your situation.  Here is a link to Medicare's discussion of coverage of insulin pumps. https://www.medicare.gov/coverage/insulin.    Yes, this falls under Part B, more specifically under the Durable Medical Equipment (DME) benefit.  The DME benefit covers the pump plus any medication used in it.  So you might ask your doctor to put you in touch with a Medicare Certified DME company that can supply both and bill Medicare for you (I'm assuming you have original Medicare and not a Medicare Advantage plan).

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Re: Will Medicare Pay for Shingrix?

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Message 6 of 37

@kfhoz 

Yes, it is too bad that the PPACA did not mandate more coverage for preventive care under Medicare - where more is free or even covered under Part B rather than Part D.

 

The list is getting smaller and smaller under Part B - Now only

  • annual flu shot
  • Hep B with some health qualifiers
  • Pneumoccal vaccines - both  - I look for these to go to Medicare Part D shortly

The reason for this, of course, is to save Medicare money - those that can pay will have to pay thus Medicare moves the preventive vaccination from Part B to Part D.  The Tdap was the last one that got switched.  

 

The Shingles vaccine - the old one and now the new one has always been under Part D.

 

Medicare.gov Video - Shots and vaccinations

 

But I am curious as to why your husband's Part D plan has it listed as so expensive.  I am wondering if it is even on the formulary with that carrier - AARP/UHC Part D - can you check?  If it is there - what tier is listed?

The new one is called Shingrix and the old one is  Zostavax.

I would assume that the pharmacy who gave him the quote is also in-network in his plan.

 

Just seems really high for just the (1) shot of  Shingrix when you have to have (2) .  But that could be right ??!!!!!  Pharma will do its thing, ya know - 

 

 

* * * * It's Always Something . . . Roseanne Roseannadanna
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Re: Will Medicare Pay for Shingrix?

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Message 7 of 37

@LeslieCY you said . . . "So much mis-information on this thread! "

 

Very true.

 

Including . . .

 

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. 

 

Maybe non-sensical but it happens.

 

Quite often I also see generic copays that are higher than cash prices. But it happens, and quite often.

 

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 

 

Again, wrong . . .

 

Drugs covered still have a copay until the deductible is satisfied. With many plans the deductible does not apply to tier 1 or 2 drugs, especially if using a preferred pharmacy.

 

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.

 

Also wrong, for reasons already stated.

 

the Affordable Care Act (which governs commercial plans) make preventive care services with $0 copays. 

 

Obamacare does not make preventive DRUGS free, only the professional services that meet preventive care criteria.

 

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.

 

Very few pharmacy's are set up to file Part B claims.

 

Just ask insulin dependent diabetics that have a pump how hard it is to find a pharmacy that can/will fill their insulin and file under Part B . . .

 

 

 


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Re: Will Medicare Pay for Shingrix?

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Message 8 of 37
The amount my husband was just asked to pay on the first injection was $174 which the pharmacy said would be "applied to the deductible". This is with AARP version of UnitedHealthCare (UNC) plan in the Seattle area. Insurance was going to cover $7 of the total cost of $181 for just the first vaccine. He did not proceed.

My work plan on the other hand (not Medicare) covered the whole thing as preventative care, both vaccines. Suggest that your working friends & relations to get the Shingrix whill still under their employers insurance.
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Re: Will Medicare Pay for Shingrix?

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Message 9 of 37
It is still not available in my area health unit.
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Re: Will Medicare Pay for Shingrix?

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Message 10 of 37

just one word -Myaarpmedicare

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