As we discussed in a December post, Shingrix is over 90% effective in preventing shingles (a painful recurrent chicken pox infection involving a single nerve), and dramatically more effective than Zostavax, the prior vaccine which we have given to many of our members. The CDC (Centers for Disease Control and Prevention) strongly recommends that everyone over age 50 get Shingrix. They say this whether or not you have previously had shingles, or Zostavax, or don’t recall ever having chicken pox. Dr. Sobel and I agree with this recommendation.
Practicalities of Administration
We have ordered initial supplies of Shingrix that should arrive early next week. We will be prepared to immunize everyone over age 50. The immunization requires two shots, separated by 2 to 6 months. The shot is safe, but there are a moderate number (5-10%) of local and systemic reactions, including sore arm, achiness, headache, fatigue and so forth. The only contraindication is a severe reaction to the initial dose of the vaccine. Egg allergy or immunosuppression are not contraindications.
Commercial Insurance Coverage
We still do not know at this moment exactly what the insurance coverage will be. Each of the two shots we administer to our patients will cost $175 plus a small administration fee. At the moment, none of the major commercial insurers (Blue Cross, Tufts, Harvard Pilgrim) have indicated they will cover Shingrix, though we expect at some point they will cover at least members over 60.
Medicare Coverage Expected, Not Yet Clear
We also do not yet have definitive information about Medicare coverage. Most likely it will be similar to the coverage for Zostavax, the previous shingles vaccine. In that case, the patient (you) needed to pay the physician’s office for the immunization, and then submit a receipt we gave you for reimbursement from the patient’s Medicare Part D drug plan. While cumbersome, that process worked well. The patient received substantial but not complete reimbursement, leaving the equivalent of a copay uncompensated.
Some drug stores now offer the Shingrix vaccine. Drug stores are allowed to bill Medicare Part D directly, so a patient getting the vaccine at a drugstore will pay a copay (determined by the patient’s Part D plan) and the bulk of the cost will be billed directly to Medicare by the pharmacy. The net financial result to the patient is about the same. Your trade-off is the simpler financial setup at the drugstore, compared to the most likely simpler availability and administration at our office (one-stop shopping, coordinated with a planned visit), but with the need for you to submit a claim for reimbursement (we provide receipts and facilitate).
Get the Vaccine This Year
We will offer Shingrix to everyone over 50 at scheduled visits. You want to get it sometime this year for your protection. Shingles is frequently terrible and this vaccine really works. Certainly as soon and if commercial insurers and Medicare definitively cover the vaccine, we will bill them according to normal rules. Until that happens, you the patient must pay. We assure you we do not get rich on vaccine profits.
You are welcome to ask questions in the comments below, or email to firstname.lastname@example.org.