Will Medicare Pay for Shingrix?

[imaprettywoman]

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. 

[JeremyM658635]

prepaidgiftbalance

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@jimarley wrote:

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

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Medicare part B does NOT cover shingles vaccination. Part D covers it as a prescription drug (even though it is a preventive vaccine). If your Medicare advantage plan covers part D (drugs) then the shingles vaccine is covered. Your copay may vary from plan to plan.

[imaprettywoman]

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. 

[LeslieCY]

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

[imaprettywoman]

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. 

[LeslieCY]

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. 

[NOTHAPPENING]

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@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.

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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!

[SaraR650827]

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!

[LeslieCY]

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.

[GailL1]

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@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.    

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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.