Shingrx shots at PCP, with Original Medicare + Part D, how does it work?

[Telly]

On my list for 2021 is to try to get Shingrx shots accomplished. All my vaccinations in the past 10 years or so have been at pharmacies, works out no problems.

But I have a PCP now, and could go there for shots. But Shingrix under Original Medicare isn't covered by Part B, but is covered under the Part D drug plan, which I have, $435 deductible, IIRC.

I could go to a pharmacy for them, and together in the same year, they would fall short of my deductible, but would put me well on the way if something else happens later in the year, drug-wise. The payment model is clear this way.

But what if I get the Shingrx shots at a physicians office? The shots themselves are covered under Part D, but the person administering them is under Part B. How do the shots themselves get paid? I pull out my Part D card at the docs? Or they attempt to charge me whatever they want for the shots themselves?

Could someone please explain the inner workings of this? Please note that this is about Original Medicare + Medigap + Part D, NOT Medicare Advantage!

 

[omni550]

I'm struggling with a similar situation.

I may just use the GoodRx discount price of $155 and go to a local pharmacy paying out of pocket, as I probably will not meet the 2020 deductible.

omni

 

[Katsmeow]

No answer but I good question. I am planning to do this as well and am not sure of the questions you ask. Hope someone knows.

 

[Sarah S]

Here is what aarp said
https://www.aarp.org/health/medicare-qa-tool/does-medicare-cover-shingles-shot/

I suspect that if you want to do the in office option you would likely have to submit it to your insurance. The physician’s office probably won’t want to deal with the paperwork or risk non payment. You might be charged a fee for administration because they couldn’t bill part b

 

[TrvlBug]

Not Shingrix, but I got a pneumonia shot last year during my wellness appt. and it was covered. Not sure if it was through Part B or D.

 

[Corporateburnout]

I had to get my two shots at the pharmacy as my doctor's office who's part of a big research hospital does not offer the Shingrix shots.

My out of pocket cost was $169 each since I didn't meet my part D deductible.

Well worth the cost in my opinion.

 

[CardsFan]

Another reminder to folks pre-Medicare:

Before Medicare, many insurance companies cover the Shingrix under medical, not drugs, (the opposite of Medicare). Often, at least in my case, no deductible, totally free. You MAY need to pay and submit yourself, if done at Walgreen's, etc. But it was covered, and we made sure to get them before medicare (for DW the last shot was actually 1 day before Medicare).

That said, I would have no problem paying the money. I have seen shingles, and it is nasty.

But, if you can get it free, why not?

 

[Sunset]

Another reminder to folks pre-Medicare:

Before Medicare, many insurance companies cover the Shingrix under medical, not drugs, (the opposite of Medicare). Often, at least in my case, no deductible, totally free. You MAY need to pay and submit yourself, if done at Walgreen's, etc. But it was covered, and we made sure to get them before medicare (for DW the last shot was actually 1 day before Medicare).

That said, I would have no problem paying the money. I have seen shingles, and it is nasty.

But, if you can get it free, why not?

I'm pre-Medicare, with funny insurance, but it is covered at the doctor office so that's where I got it before I go on Medicare.

 

[CountryBoy]

I’m appreciating my Obamacare more each year, still 5 years from Medicare. I got my second Shingrix shot on Saturday at Rite-Aid, at the pharmacy counter. They scanned my insurance card and said no charge. I also got a flu shot there the same day.

(And yes it IS nasty; my 57 year old sister got shingles in July, godawful rashes down her one arm & back, a searing burning in her back as well. She was in misery for weeks.

 

[frank]

checked the local hyvee the other day and the shot was 155 and still in the deductible stage. the thing is they wanted to charge another 25. on top of that for administration fee. anyone run into that with the goodrx coupons?

 

[kaneohe]

Another reminder to folks pre-Medicare:

Before Medicare, many insurance companies cover the Shingrix under medical, not drugs, (the opposite of Medicare). Often, at least in my case, no deductible, totally free. You MAY need to pay and submit yourself, if done at Walgreen's, etc. But it was covered, and we made sure to get them before medicare (for DW the last shot was actually 1 day before Medicare).

That said, I would have no problem paying the money. I have seen shingles, and it is nasty.

But, if you can get it free, why not?

This seems like a good idea. The El Cheapo Medicare Pt D plans (like the Humana Walmart plan) appear not to cover the Shingrix shot so ,at least on the Medicare site, your cost would be $1500+ tho there might be cheaper alternatives elsewhere.

 

[H2ODude]

What few meds we get are all priced at the generic from Walmart. That's where our Part D is, Humana. I think it was on here somebody mentioned that they did not really disclose a new $10 a month Humana plan vs what had been the least expensive of about $35. We just want the cheapest so we don't get dinged later for not having been on a plan. Anyway, as expected no coverage for Shingrex, just got my first yesterday. I don't think the cheapo $35 paid either, but for 2x $172 and low probability of shingles, I'll pay it gladly. BTW, first vaccine I've had that did actually give me a sore shoulder. Not bad though.

 

[frank]

This seems like a good idea. The El Cheapo Medicare Pt D plans (like the Humana Walmart plan) appear not to cover the Shingrix shot so ,at least on the Medicare site, your cost would be $1500+ tho there might be cheaper alternatives elsewhere.

I can get the shingrix through my insurance for 175 each but if they price it on insurance at 1500 each would that put you close to or in the coverage gap? not sure how this coverage gap deductible thing works.

 

[MBSC]

The El Cheapo Medicare Pt D plans (like the Humana Walmart plan) appear not to cover the Shingrix shot so ,at least on the Medicare site, your cost would be $1500+ tho there might be cheaper alternatives elsewhere.

This is a common mistake. Medicare.gov has two issues when it comes to pricing Shingrix. First, it defaults to a pack of 10 so you have to change that. Second, the frequency defaults to monthly or 12 shots. There is no option for 1-2 shots because the Medicare.gov minimum frequency is 4 shots (one every 3 months). When you look at the plan details, most cheap Part D plans have a monthly Shingrix price of $150-$175 so two months (two shots) are $300-$350. You pay this amount if the plan deductible has not been met.

Or they attempt to charge me whatever they want for the shots themselves?

This. Assuming the office has Shingrix, the more likely scenario is you pay ~$170 up front, you submit a claim to Part D, and ~$150 (their rate) is credited to the deductible.

I agree this should be on the list of things to do before Medicare.

But I have a PCP now, and could go there for shots.

Even if the office says they can file to Part D, they have little experience doing it so the chance it goes sideways is higher. Just because you can do something doesn't mean you should.

 

[kaneohe]

This is a common mistake. Medicare.gov has two issues when it comes to pricing Shingrix. First, it defaults to a pack of 10 so you have to change that. Second, the frequency defaults to monthly or 12 shots. There is no option for 1-2 shots because the Medicare.gov minimum frequency is 4 shots (one every 3 months). When you look at the plan details, most cheap Part D plans have a monthly Shingrix price of $150-$175 so two months (two shots) are $300-$350. You pay this amount if the plan deductible has not been met.

This. Assuming the office has Shingrix, the more likely scenario is you pay ~$170 up front, you submit a claim to Part D, and ~$150 (their rate) is credited to the deductible.

I agree this should be on the list of things to do before Medicare.

Even if the office says they can file to Part D, they have little experience doing it so the chance it goes sideways is higher. Just because you can do something doesn't mean you should.

Thanks! Hope you're right.....saw that pack of 10 thing so changed something to 1 but wasn't sure that was fixing it........but that's where the $1500 came from. Still can't get it to get the $150.

 

[Telly]

.........This. Assuming the office has Shingrix, the more likely scenario is you pay ~$170 up front, you submit a claim to Part D, and ~$150 (their rate) is credited to the deductible.

.........Even if the office says they can file to Part D, they have little experience doing it so the chance it goes sideways is higher. Just because you can do something doesn't mean you should.

Here is what aarp said
https://www.aarp.org/health/medicare-qa-tool/does-medicare-cover-shingles-shot/

I suspect that if you want to do the in office option you would likely have to submit it to your insurance. The physician’s office probably won’t want to deal with the paperwork or risk non payment. You might be charged a fee for administration because they couldn’t bill part b

Thanks for the info!
That settles it! I will NOT be seeing my new PCP for Shingrix! And I really like the freedom and ease of getting vaccines at a pharmacy. Next month, I want to get the Fluzone High-Dose and the first pneumonia shot. I'll probably call the PCP office for that, since those are non-Part Ds. If I can get those there without a big rigamarole. Meaning, I go in, nurse or PA shoots me, and I leave. Otherwise, I'll be tempted to go back to pharmacies.

 

[Rushmore]

I had to get my two shots at the pharmacy as my doctor's office who's part of a big research hospital does not offer the Shingrix shots.

My out of pocket cost was $169 each since I didn't meet my part D deductible.

Well worth the cost in my opinion.

my thoughts exactly. I’ve known several people with post hepatic neuralgia...their lives were miserable. One was a sweet elderly neighbor who ended up in a nursing home, when previously she was mowing her own lawn shoveling her own snow. She never recovered