Sunday, July 14, 2024

Is Shingles Shot Covered By Medicare Part D

What Is Shingles And How Do You Catch It

Relief coming to those on Medicare who can’t afford shingles vaccine

Shingles is a painful skin rash that forms on one side of the body. It is caused by the same virus that causes chickenpox, the varicella-zoster virus. Shingles can affect people who have had chickenpox, even if they had the illness long ago.

Once youve had chickenpox, the virus becomes inactive in the body and can reactivate years later. The virus can remain inactive in your nerve roots for many years, and then wake up and travel down the path of a sensory nerve to the skincausing shingles. You may develop shingles more than once in your lifetime.

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What Are The Complications Of Shingles

The most common and lasting complication of shingles is nerve pain, whats called postherpetic neuralgia , which can last for months or even years, long after the rash has cleared up. According to the CDC, between 10% and 18% of people whove had shingles will develop PHN.

PHN is a stabbing or throbbing pain or weakness where the shingles rash had been. The risk increases with age and the pain lasts longer and is more severe than in younger people.8

In rare cases, shingles can develop into pneumonia, hearing problems, blindness and brain inflammation.9 Only 1% to 4% of people with shingles are hospitalized for complications, though these are typically older adults and people whose immune systems are weak or suppressed, and fewer than 100 people die from shingles each year.10

Some Vaccines Covered Better Than Others

Unlike the flu and pneumonia vaccines, which are fully covered as preventive services under Medicare Part B, the shingles shot and other recommended vaccinations are covered as prescription drugs under Medicare Part D and Medicare Advantage plans.

Some of those plans provide better coverage than others, but nearly all of them divide their formularies, or list of covered drugs, into tiers according to cost. Drugs in Tier 1 and 2, mainly lower-priced generics and preferred brand-name drugs, have lower co-pays than more expensive nonpreferred brands in Tier 3 or 4.

Consumer Reports found that many Part D plans categorize the shingles vaccine, Zostavax, as an expensive Tier 3 or 4 drug. Only one pharmaceutical companyMerckmakes the shingles shot, and theres currently no generic version.

That means if you havent met your annual deductible, youll likely wind up paying full price for the shot, which is about $217. But depending on your plan, even after the deductible is met, consumers may have to pay a significant part of the shingles vaccine costup to $100.

Many healthcare providers havent set up billing systems to file claims through prescription drug plans. So if you’re vaccinated at your doctors office, you might be required to pay the full shingles vaccine cost up front and then file to be reimbursed by your insurance.

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Medicare Coverage For Shingles Vaccine

Shingrix is not the first shingles vaccine, but it is the only one currently on the market in the United States.Instead of using a live virus,the vaccine uses a protein from the virus to trigger an immune response. It is administered in two doses two to six months apart.

This shingles vaccine has been shown to decrease the risk for shingles by 97% for people between 50 and 69 years old and by 91% for people 70 and older. It reduces complications as well. The risk for post-herpetic neuralgia goes down by 91% and 89%, respectively, in those age groups.

Because the vaccine works well, it is important to know if and when Medicare covers it.

Who Should Not Get The Shingles Vaccine

Your Medicare Experts

The vaccine may not be appropriate for people who have a weakened immune system due to certain conditions. These people include those with an organ transplant and those who are undergoing chemotherapy to treat cancer.

Doctors also recommend that people with an allergy to any component of the vaccine do not have the shingles vaccination.

Anyone with severe allergies must tell a doctor about them when discussing their shingles risk. People who are pregnant or breastfeeding or currently have shingles symptoms should not get the shot.

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Shingles Shot Will Be Free For People With Medicare Part D Starting January 2023

About 1 out of every 3 people in the United States will develop shingles in their lifetime, the Centers for Disease Control and Prevention estimates.

Shingles, a reactivation of the chickenpox virus, typically causes a painful, itchy rash on a persons body that can linger for months or even years. Anyone who has ever had chickenpox can get shingles, including children, but people who are older or those with weakened immune systems are at increased risk.

In a 2019 report to Congress, the Medicare Payment Advisory Commission found that the shingles vaccines cost which can be more than $400 for the required two doses if a Medicare recipient hasnt met their deductible may pose a barrier to vaccination.

VERIFY reader Patricia recently texted the team to ask whether Medicare will start paying for the shingles vaccine in 2023.

Who Should Get The Shingrix Vaccine

The Shringrix shingles shot is recommended for adults age 50 and older.

The Shingrix shingles vaccine is more effective than Zostavax. Shingrix is more than 97% effective in preventing shingles in adults 50 to 69 years old after two doses. The Shingrix shingles vaccine is 91% effective in preventing shingles in adults age 70 and older, according to the CDC.

CDC recommends two doses of the vaccine to prevent shingles and related complications in adults 50 years and older. For adults 19 years and older who have weakened immune systems, the vaccine is also recommended.

There is no age limit for receiving Shingrix, and it is recommended to get the shot if:

  • You have previously had shingles
  • You have received Zostavax
  • You have received the chickenpox vaccine

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You Wont Pay For Medicare Vaccines In 2023

You won’t pay for Medicare vaccines in 2023.

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For you, a vaccination is a vaccination it protects you against something. But, under Medicare, all vaccines are not equal and that means you probably paid more for some than for others.

The coverage for a vaccine depends on the part of Medicare under which it falls.

Part B, medical insurance, covers most vaccines that Medicare beneficiaries need. There is no copayment for those that every Medicare beneficiary should get, specifically:

Those who chose Original Medicare can get the vaccine from any doctor or pharmacy that accepts Medicare assignment. Medicare Advantage plan members should visit a doctor or pharmacy in the plans network. No matter the type of Medicare you have, there is no deductible, copayment or coinsurance.

Public service announcement about the flu

During the 2020-2021 flu season, flu was practically nonexistent. Thats because of all the handwashing, masking, sheltering at home and social distancing we did to control the spread of Covid. The impact of all these practices carried over into the next year with another mild flu season. But that may change this year.

That will change as of January 1, 2023. Just as with the flu, Covid and pneumonia vaccinations, Part D vaccines will not be subject to a deductible and there will be no copayment. Keep these points in mind.

Prescription Drug Plans Cannot Charge You More Than $35 For A One Month Supply Of Each Covered Insulin That You Are Prescribed Companies Can Also No Longer Charge You A Deductible For Those Drugs

Medicare & You: Vaccines

What if I usually get 90 day prescriptions? The same thing applies, you can only be charged $35 for each month, therefore the maximum for a 90 day supply would be $105.

What if I use an insulin pump to administer my medication? If you take your insulin through a traditional pump, your insulin then falls under Medicare Part B, or durable medical equipment coverage.

Medicare has given plans until March 2023 to update their systems to reflect this new cost of covered insulin. You may get charged more if you pick up your insulin in January or February, however your plan then has 30 days to reimburse you for the difference should you end up overpaying.

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Solving The Part D Oop Problem

When the MMA was passed, vaccine OOP costs were only a theoretical problem. Then, in 2005, the first pertussis-containing vaccine for adults was licensed, followed by the first shingles vaccine in 2006. A 2011 GAO report showed that relatively few Medicare beneficiaries received these vaccines, and cost sharing was cited as a barrier to access.

A 2018 Avalere Health analysis I led found that uptake of the shingles vaccine was 40% to 60% higher when a Part D plan offered $0 cost sharing. In 2016, 95% of Part D beneficiaries encountered vaccine cost sharing, with OOP costs averaging $85. Other studies have affirmed that cost sharing is a definite barrier to vaccine access, resulting in lower uptake.

Over the years, the CMS has encouraged Part D plan sponsors to offer a $0 or low cost-sharing formulary tier for vaccines, but the offering remained optional. Passage of the Inflation Reduction Act now makes this mandatory and removes a barrier to vaccine uptake.

Congress Finally Eliminates Part D Vaccine Cost Sharing: Medicare Coverage Is Still Broken

The Inflation Reduction Act leaves intact a peculiar split in Medicare vaccine coverage that discourages physicians from offering certain vaccines, former Moderna Vice President Richard Hughes argues.

Editors note: Richard Hughes is a member of the firm Epstein Becker Green in the Health Care & Life Sciences practice and a former vice president for Moderna.

In its passage of the Inflation Reduction Act of 2022, Congress has taken the long overdue step of eliminating out of pocket, or OOP, costs for vaccines under Medicare Part D. The OOP prohibition aligns with policies under Medicare Part B and the Affordable Care Act and removes a pharmacy counter barrier that will undoubtedly lead more seniors to be vaccinated against shingles. However, it leaves intact a peculiar split in Medicare vaccine coverage that discourages physicians from offering certain vaccines.

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What Is The Cost Of The Shingles Vaccine With Medicare Part D

Since every insurance plan is different, each Part D plan provides varying degrees of coverage for the shingles vaccine. Some plans may place the vaccine in Tier 1 while others may put it under Tier 3 . Some plans may also have a deductible, meaning 100% of your vaccination or drug costs are on you until you meet the dollar amount specified by your insurance plan.

The best way to know how much a shingles vaccine may cost you is to call your insurance provider and ask.

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What Are The Two Types Of Shingles Vaccines

The two options for the shingles shot are Zostavax and Shingrix. Zostavax, according to the Mayo Clinic, protects against shingles for about five years. Itâs a live vaccine given as a single shot in the upper arm. The Zostavax shingles shot is recommended to adults age 60 and over which reduces the risk of developing shingles by 51%, according to the Centers for Disease Control and Prevention .

Studies suggest that Shingrix offers protection against shingles for more than five years. Itâs a nonliving vaccine given in two doses.

Why Does Medicare Not Cover The Shingles Shot

There are a few reasons why Medicare Part A and Part B do not cover the shingles vaccine. One reason is that the vaccine is not considered to be medically necessary. Medicare only covers preventive care services that are considered medically necessary. Instead, your shingles shot will be covered if you have Medicare Part D, which covers prescription drugs.

Another reason Medicare does not cover the vaccine is that it is not considered to be cost-effective. Medicare only covers preventive care services that are considered to be cost-effective. The shingles vaccine is not currently considered to be cost-effective by Medicare standards in some cases.

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What Parts Of Medicare Cover The Shingles Vaccine

Original Medicare Part A and Part B doesnt cover the shingles vaccine. However, there are other Medicare plans that may cover at least part of the costs. These include:

  • Medicare Part C. Medicare Advantage is a plan you can buy through a private insurance company. It may offer additional benefits not covered by original Medicare, including some preventive services. Many Medicare Advantage plans include prescription drug coverage, which would cover the shingles vaccine.
  • Medicare Part D. This is the prescription drug coverage portion of Medicare and typically covers commercially available vaccines. Medicare requires Part D plans to cover the shingles shot, but the amount it covers can be very different from plan to plan.

Making Sure Youre covered

There are a few steps you can take to make sure your shingles vaccine is covered if you have Medicare Advantage with drug coverage or Medicare Part D:

  • If your doctor cant bill your plan directly, ask your doctor to coordinate with an in-network pharmacy. The pharmacy might be able to give you the vaccine and bill your plan directly.
  • File your vaccine bill for reimbursement with your plan if you cant do either of the options above.

If you have to file for reimbursement, youll have to pay the full price of the shot when you get it. Your plan should reimburse you, but the amount covered will vary based on your plan and if the pharmacy was in your network.

Where And How To Get Vaccinated For Shingles

Shingles: Signs, Symptoms and Treatment with Dr. Mark Shalauta | San Diego Health

Medicare requires all Part D plans to cover the shingles vaccine. However, since Part D plans have networks, youll want to be sure you get the vaccine at a pharmacy in the plans network.

Do not get the shingles vaccine at your doctors office. Doctors offices dont have the ability to bill Part D plans. Therefore, getting the vaccine at your doctors office could result in you paying the entire bill and having to submit a reimbursement request to your plan.

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Does Medicare Cover Shingles Vaccine

  • Medicare with Melissa

Great news! Starting in 2023, Medicare will cover the shingles vaccine under Medicare Part D and Medicare Advantage Plans , meaning you wont have to pay any deductible, copay, or any other costs for the vaccine. It is important to note that the shingles vaccine is not covered under Medicare Part A or Part B.

Vaccines Covered By Medicare Part D

Medicare Part D covers all commercially available vaccines needed to prevent illness. You can get Part D coverage through a stand-alone Medicare prescription drug plan or a Medicare Advantage plan that includes drug coverage.

Vaccines covered by Part D include the following:

  • Shingles vaccine: One-time vaccine given in two shots over two to six months
  • Tdap vaccine : One shot if youve never been vaccinated, and a booster every ten years
  • Other vaccines covered: Vaccines that are “reasonable and necessary” to prevent illness and are not covered by Part B

Part D may also cover vaccines you may need if you are traveling internationally. Talk with your doctor about your travel plans and ask what vaccines are recommended.

Read Also: What Is Shingles And How Do You Get It

Restrict Growth In Drug Prices To Inflation

Another new provision that could help seniors indirectly requires drug companies to pay rebates if they hike their prices in Medicare faster than inflation.

The rebates will be deposited in the Medicare trust fund that helps finance the Part D program, as well as the Part B program, which covers physician services.

This is aimed at restraining the annual increase in drug prices, which would slow the hikes in premiums and cost sharing that seniors face.

How Does Medicare Provide Coverage For The Shingles Vaccine

Is The Shingrix Vaccine Covered By Medicare

Medicare prescription drug plans and Medicare Advantage plans that provide prescription drug coverage generally cover all commercially available vaccinations. These plans will cover the vaccination medication and the administration of the shot by your doctor or physician. Depending on your plan benefits, you may have to pay a copayment or coinsurance amount. Make sure to follow your planâs guidelines for this vaccination to be covered.

You will pay the least amount of money out of pocket if you are vaccinated at a pharmacy in your drug planâs network. A summary of ways you can pay for your shingles vaccine include:

Medicare

  • Medicare Part D plans cover the shingles vaccine. There may be a copay, or you may need to pay the full amount and get reimbursed for some of the cost.
  • Original Medicare Part B does not cover the shingles vaccine.

Medicaid

  • To learn if your Medicaid coverage pays for the Shingles vaccine, please contact your Medicaid insurer.

Private health insurance

  • Private health insurance plans cover the vaccine, but there may be some costs depending on your plan.

Vaccine assistance programs

  • Some pharmaceutical companies provide vaccines to those who are eligible and unable to afford costs. C with the vaccine manufacturer, GlaxoSmithKline, about if Shingrix is covered by these programs.

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