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Will Medicare Pay for Shingrix?

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

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Periodic Contributor

The asnwer is NO unless you happen to enroll in a Part D plan that covers it, or if you are in an Advantage Plan that covers it. I have the AARP Medigap plan and they don't cover it.

I found one Part D plan that covered it, but the plan only provide 50% reimbrsement, and the premium for that plan is $500 higher than the others, so you end-up paying more in the end.

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Bronze Conversationalist

If your drug plan provides a copay that is less than $150 per shot, go with it. Otherwise pay cash.

 

You don't NEED a drug plan to get the Shringrix vaccination.

 

Check prices in your area. Costco in Atlanta offered the drug for around $140 per shot a year or so ago.

 

GoodRx pricing currently has it at $151 at select pharmacy's.

 

GSK has a coupon that may allow you to obtain the medication at a lower copay.

https://www.gskforyou.com/vaccines-patient-assistance/

 

This thread is almost 2 years old with over 50 responses. Time to move on.


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Apparently NOT.

Plans, availability and prices change every day.

If you're not interested, don't read this thread anymore.

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No it was not covered. I have AARP Medicare Supplement  Plan F and it does not cover vaccinations. My claim was denied. I also have a prescription Plan D and it also did not cover Shingrix.  So I had to pay $300 for two shots. Just shows you that all the talk about the focus on providing preventive care is just BS. 

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I went to CVS last week after my doctor mentioned it.  $8.99 for the 1st shot with AARP Medicare Advantage 2, so I imagine the 2nd shot in a couple of months will be the same.

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I have AARP Complete Medicare Advantage and went to CVS last week, $47 for 1st shot, and I believe the same for the 2nd dose later on.
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 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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Bronze Conversationalist

@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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i did some more research since my first comment. The clerk at CVS said I would be covered (she tried several different options), but the co-pay was very high. I tried Good RX & the lowest price I could find  was $150. Then I searched some more. I located this year's and next year's Formulary for my Part D plan. Shingrix is not in the 2018 Formulary, but is in the 2019. So since I already have the original Shingles vaccine I'll wait until 2019 to get Shingrix. Thanks for your response. 

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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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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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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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Newbie

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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Honored Social Butterfly

@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 - 

 

 

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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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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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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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Super!

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Nothing at that link about Shingrix!

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Nothing there about Shingrix !

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Periodic Contributor

We are in same boat. You just saved me $344 for the original and the follow up at Salt Lake Country Health Department.
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Contributor

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.

 

Someone mentioned it, but GoodRX (https://www.goodrx.com/shingrix/medicare-coverage) had the prices as of today and I found this database as well (https://www.howmuchisit.org/shingrix-cost/) which explained the insurance situation.

 

In the end, just talk with your doctor or the pharmacy.  I had my Medicare information and found out it didn't cover it, but ended up paying about $150 for it.

 

I hope this helps everyone!

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Regarding Part D Coverage of Shingrix specifically (note that this is a two dose schedule unlike Zostavax which is one dose):

I would be surprised that a plan covers Zostavax but does not cover Shingrix given that Shingrix if much more effective- this according to ACIP, the Advisory Committee on Immunization Practices which operates under the auspices of the CDC. Www.cdc.gov. ACIP states that Shingrix is preferred over Zostavax and recommends that people who already got Zostavax now get Shingrix. 

 

It it is possible I suppose that a Part D plan covers only Zostavax but if so, that’s a lousy plan. Yes, it is an expensive proposition for the plan to now pay for Shingrix. 

 

I work with doctors in Medicare Advantage Plans that pair Medicare A/B coverage with Part D, referred to as MAPD plans. Or you may have purchased a standalone PDP just for Part D. Either way I find that doctors are among the least informed about this topic!  Better to talk you your Prescription Drug Plan rep about Shingrix. Even if they “cover” Shingrix the cost may be applied against your Deductible and/or in a high tier on their formulary that carries a high coinsurance so your out of pocket could be high. But it at least applies against your deductible and you get the benefit of the plans discounted rate. 

 

If if you go to a pharmacy for Shingrix be sure it is a plan-contracted pharmacy and don’t forget to come back for the second dose and also advise your doctor that you got this.  We have doctors who give the vaccine to people on Medicare and then can’t bill the Part D plan because the plan is accustomed to paying pharmacies through an online Pharmacy Benefit Management system and simply will not accept a medical claim from the doctor. So then the doctor asks you to pay and then you request reimbursement from your Part D plan. More expensive and hassle for you. There is a way for your doctor to get paid if he is enrolled in www.transactRx.com if linked to your Part D plan. That system can tell your doctor what your share of cost is right at the time you get this. 

 

 

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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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Honored Social Butterfly


@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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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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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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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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My doctor says it is "highly ineffective" anyway! Take that for what you may...

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