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Shingrix Vaccine Reimbursement Under Medicare Part D

The Shingrix vaccine is an important advance in protecting susceptible patients from shingles (officially known as herpes zoster), a painful blistery inflammation of a single peripheral nerve that occurs because of a reactivation of chicken pox virus resident in the person’s body from prior chicken pox infection. This mainly affects people over 50 years of age. Since almost all children have been immunized against chicken pox (varicella) with Varivax since that vaccine was introduced in 1995, shingles should eventually disappear. But it is still very much with us.

Shingrix vaccine introduced in 2018

About two years ago, GlaxoSmithKline introduced Shingrix, its new and highly effective vaccine again shingles, recommended by public health bodies for all people over 50. We have been administering Shingrix since spring 2018, but availability in fact has been scant. Mostly hat, not many cattle. So we are still at it and many of you have yet to get the vaccine. We did prioritize those most at risk, which includes our older patients and those with immunocompromise and those who never got Zostovax, the original vaccine from over a decade ago that was much less effective but still had value.

We plan to get more Shingrix to our patients

But supplies at last are improving. We plan to move ahead and try to offer the vaccine to everyone over 50, with some confidence that supplies will keep up so we will not run out and have to ration the doses as we have had to do until recently. Please remember that two shots are required, separated by 2 to 6 months. And significant adverse reactions including fever and malaise lasting several days, or substantial local reactions, occur in about 15% of recipients, although fortunately the vast majority of people (85%) have modest local injection annoyance.

Commercial insurance coverage

Shingrix is fully covered on commercial insurances (Blue Cross, Tufts, HPHC, United, etc.) with usually no deductibles or copays. We bill the insurer and the patient is not usually involved financially.

Shingrix coverage under Medicare Part D

The cost of Shingrix is covered under Medicare Part D plans and is usually subject to copays, which apply wherever you get the immunization.

You can get the immunization at most pharmacies, now that they also have supplies. In that case, you will pay your Part D plan’s copay for Shingrix plus an administration fee charged by the pharmacy. The pharmacy bills Medicare Part D for their reimbursement for the cost of the immunization not covered by your copay. If you get Shingrix at a pharmacy, please let us know so we can note that in your record.

Coverage for office administration under Part D

We at Orchard Health Care are also ready to and have been administering the shots to many of you. We think, as do most of you, that our office is a more comfortable setting for this process, and the shot can usually be combined as part of a scheduled visit for other reasons.

Doctors’ offices cannot invoice Medicare Part D directly. So, in our office, you need to first pay us for the vaccine, which is moderately expensive. Our charge for each Shingrix and administration is $230. You then submit a receipt for the shot to your Medicare Part D together with one of the insurer’s forms for subscriber reimbursement for covered patient-paid expenses (including drugs and covered immunizations in doctors’ offices). You are supposed to receive back from your Part D plan the difference, or most of the difference, between what you paid us and your Part D’s copay for the shot. Our admin staff can help you get the correct form and will provide a receipt.

Administrative difficulties overcome

To date, getting the details from the Part D plans, including clear statement that Shingrix is covered and the specific reimbursement form to be used for each plan, has been more than a bit elusive. That left some of you unreimbursed last year, which is wrong. We went to correct that situation this past week. After more than a trivial amount of bureaucratic sleuthing, we determined that:

  1. Medicare Part D plans must cover Shingrix by regulation;
  2. Each plan may have different Shingrix copays, even within one insurer, with some examples varying from $43 to $71 to $90 per shot, not counting the pharmacy administration fee;
  3. The Shingrix cost may be applied against your deductible for that drug plan;
  4. At least four of the major Part D plans have the appropriate forms easily findable on their websites (which is encouraging, since last year we all thought they were hiding them). These include Wellcare, Express-Scripts, Humana, and Blue Cross. We expect the reimbursement forms will be easily located for any other Part D plan that you may have.

In summary

You should get the Shingrix vaccine if you are over 50 and have not yet had it. Supplies have been improving. We will continue to offer the Shingrix shots in our office for everyone. If you have commercial insurance, we bill the insurer. If you have Medicare, you pay us and we help you get reimbursed from your Medicare Part D. And you may of course still go to your pharmacy to get the shot. Your cost will be similar in either venue. Just let us know if you use your pharmacy.

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