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).
