New Shingrx Shingles Vaccine

[Human]

I plan on getting it. Here’s an article I saved from Nov to remind me to look into it this year, for those that are interested in learning the basics:

https://www.usatoday.com/story/news/...-me/867046001/

[Chuckanut]

I had the old vacine years ago so I probably should get the new one. I think I will give it a while longer, just to make sure there are no 'surprises' and then get it.

[Done]

I got the Shringrix vaccination at Costco Pharmacy. It appeared that my HDHP insurance plan did not cover it at all, although I had seen literature online indicating that it was a covered vaccine. I called insurance CS and they determined that it was 100% covered at age 50+, but it is a medical benefit, not a pharmacy benefit. The billing systems are separate.

They asked me to pay the $156 out of pocket and guaranteed that they would reimburse me if I mail in a medical reimbursement form. Good to know in case it at first appears that the vaccination is not covered. I'm due for my second dose in 2-6 months, but the pharmacist recommended waiting closer to 6 months.

[foxcreek9]

BCBS Illinois covered mine yesterday, no copay.

[gauss]

Quote:

Originally Posted by Done I got the Shringrix vaccination at Costco Pharmacy. It appeared that my HDHP insurance plan did not cover it at all, although I had seen literature online indicating that it was a covered vaccine. I called insurance CS and they determined that it was 100% covered at age 50+, but it is a medical benefit, not a pharmacy benefit. The billing systems are separate. They asked me to pay the $156 out of pocket and guaranteed that they would reimburse me if I mail in a medical reimbursement form. Good to know in case it at first appears that the vaccination is not covered. I'm due for my second dose in 2-6 months, but the pharmacist recommended waiting closer to 6 months.

Hmm - Wouldn't you pay 100% of the cost until your deductible of your HDHP is met (especially if they are calling it medical)?

My experience is the only things that evade the deductible are things classified as screening/prevantitive.

I have not specifically had any vaccines under these plans however.

-gauss

[Gotadimple]

Quote:

Originally Posted by gauss Hmm - Wouldn't you pay 100% of the cost until your deductible of your HDHP is met (especially if they are calling it medical)? My experience is the only things that evade the deductible are things classified as screening/prevantitive. I have not specifically had any vaccines under these plans however. -gauss

Under most plans, this vaccination is not subject to the deductible. Mine wasn't when it was administered in the doctor's office.

I think the distinction between medical vs. drug benefit might have to do with the drugs that are provided by the pharmacy benefit manager used by the insurer. The PBM buys the drugs in bulk, arranges for a network of pharmacies to provide injection services, and the plan pays the pharmacies a dispensing fee.

- Rita

[wmc1000]

According to the GSK website, https://www.gsksource.com/pharma/con.../coverage.html , broad payer support is not expected until April 2018.

[ziggy29]

Quote:

Originally Posted by Done I got the Shringrix vaccination at Costco Pharmacy. It appeared that my HDHP insurance plan did not cover it at all, although I had seen literature online indicating that it was a covered vaccine. I called insurance CS and they determined that it was 100% covered at age 50+, but it is a medical benefit, not a pharmacy benefit. The billing systems are separate. They asked me to pay the $156 out of pocket and guaranteed that they would reimburse me if I mail in a medical reimbursement form. Good to know in case it at first appears that the vaccination is not covered. I'm due for my second dose in 2-6 months, but the pharmacist recommended waiting closer to 6 months.

This is very new to insurers and is still being worked up. Many private insurers (mine included) link their first-dollar preventative coverage to the guidelines by the ACIP and the CDC. Apparently they made some preliminary approvals to the guidelines to change from Zostavax at 60 to Shingrix at 50 last November and were awaiting final CDC approval. Apparently, the language has changed at the CDC website to make me think this is finalized.

That being the case, my insurance should be covering it now (or very soon) since it appears the guidelines have now officially changed. I'll have to call my insurance plan to confirm it, but if they confirm it, my next call will be to schedule an immunization for it. And I'm sure DW will follow in June when she turns 50.

Quote:

Originally Posted by gauss I have not specifically had any vaccines under these plans however.

Flu shots, for example, are almost always considered preventative, as are most childhood immunizations. As has the shingles vaccine for folks over 60, but that's changing to 50 now with a different vaccine.

[omni550]

I have my Medicare Supplemental (Plan G) with Aetna.

According to their site , they cover Shingrx.

(I'm assuming the deductible will apply.)

http://www.aetna.com/cpb/medical/data/100_199/0115.html

omni

[audreyh1]

My plan covered the old vaccine three years ago even though I hadn’t met the deductible because it was preventative. I think they covered all vaccines. I got it at Costco.

High deductible ACA plan. And I was only 55!

[Huston55]

Have confirmed with GP & primary pharmacy (which gives it) that it’s recommended, available & covered. Plan to get it shortly. FYI, had the older shingles vaccination in the past.

[Dtail]

Will be checking it out with GP within 2 months. Some scary shingles stories posted here.

[gauss]

Quote:

Originally Posted by Huston55 Have confirmed with GP & primary pharmacy (which gives it) that it’s recommended, available & covered. Plan to get it shortly. FYI, had the older shingles vaccination in the past.

Interesting.

I can see GP and pharmacy speaking to the recommended and available issues, but can they speak to insurance coverage? Doesn't your insurance company determine that?

-gauss

[Huston55]

Quote:

Originally Posted by gauss Interesting. I can see GP and pharmacy speaking to the recommended and available issues, but can they speak to insurance coverage? Doesn't your insurance company determine that? -gauss

I asked my pharmacist, who knows our insurance, if it’s covered & he said yes. But, technically, you’re correct; I need to confirm with insurance to know for sure.

[wmc1000]

Omni550 - typically vaccinations are covered under Part D RX and not Part G Supplement. Aetna has both, my wife has Aetna Plan G and also Aetna Part D plans.

[Dreamer]

I am covered under FEP Blue Cross/Blue Shield and called them last week to see if they cover the new vaccine. She told me that they do not cover it yet. They did cover the older shingles vaccine for me when I was in my 50's. I did get Shingles after receiving the vaccine, but had a very mild case. I plan on getting the new vaccine as soon as insurance covers it.

[zinger1457]

Quote:

Originally Posted by Huston55 I asked my pharmacist, who knows our insurance, if it’s covered & he said yes. But, technically, you’re correct; I need to confirm with insurance to know for sure.

I would definitely check with the insurance company. When I asked my doctor for the old shingles vaccine a few years ago he insisted it wasn't covered and that I would have to pay the OOP cost but I had confirmed it was covered beforehand with my insurance company. I checked my BCBS-AZ plan documents and it states that the shingles vaccine is covered as preventative but with a side not stating that it only requires one dose so that makes me wonder if the new vaccine is also covered. I've contacted BCBS for clarification.

[Done]

Quote:

Originally Posted by gauss Hmm - Wouldn't you pay 100% of the cost until your deductible of your HDHP is met (especially if they are calling it medical)? My experience is the only things that evade the deductible are things classified as screening/prevantitive.

They consider listed immunizations to be preventative, along with an annual exam, occasional screening colonoscopy, etc. The plan covers these at 100% with no deductible.

[testing321]

I have the Humana Medicare Part D Walmart prescription coverage, and I just checked their website and Shingrix is now covered as a tier 4 drug. Since I am still in the deductable phase, it says my cost is $140.23. I presume that I would pay this twice. Wifey has employer provided coverage through Cigna, and it appears to be covered as well under preventative (no cost, lucky her).

[CaptTom]

Called my insurer (Cigna) and the person had never heard of Shingrx, or even that there was a "new" shingles vaccine. She checked with someone else, and here's the interesting part:

She said to tell the provider to use the same procedure code as the old shot, and they'll cover it. I asked if there was anything special needed, since it's a course of two shots instead of one. She checked and said no, just enter the same code twice.

CVS/Walgreens said the can do the shot on a walk-in basis, handle the insurance and don't need a doctor's prescription.

YMMV, but it looks like I'll be getting a shot soon.