Does Anthem Cover Shingrix Vaccine

Getting Shots And Vaccines With Your Health Insurance

Vaccines are important for protecting you from preventable diseases like measles, meningitis, and the flu. Vaccines prepare your immune system to fight diseases without making you sick, so that when you’re exposed to the real thing, you can save your days off of work for something more fun than lying in bed with a splitting headache and a burning throat.

Administering And Storing Shingrix

• Adults 50 years and older should receive 2 doses of Shingrix. Give the second dose 2 to 6 months after the first.
• Administer Shingrix intramuscularly in the deltoid region of the upper arm with a 1- to 1.5-inch needle.
• Both vials of Shingrix must be refrigerated at a temperature of 36-46° F. Do not use if exposed to temperatures below 36° F.

Why Do You Need The Shingles Vaccine

In a word: pain. Shingles commonly appears as a rash, usually across one side of your chest, abdomen or face. What starts as itching or tingling becomes an extremely painful band of blisters. These usually scab over in seven to 10 days and clear up in two to four weeks.4

Shingles is most common among people over the age of 50, so the Centers for Disease Controls recommends the vaccine for anyone over that age.

People with a weak immune system are at even higher risk. Your immunity may be weakened if you:5

• Are under extreme stress.

Shingles must be active, meaning in the blister phase, to be contagious. You cannot transmit the virus before the blisters appear, nor once they crust over.6 Even if the virus is active, the risk of spreading VZV is low if you keep the shingles rash covered.7

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Where And How To Get Vaccinated For Shingles

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.

Which Medicare Providers Cover The Shingles Vaccine

Even though all insurance plans for Medicare Plan D offer some level of coverage for the shingles vaccine, the typical cost for the vaccine will vary. Your actual cost will depend on your plan details and if you’ve already met your deductible.

Typical costs based on available plans in Charlotte, NC , Boston, MA , and Los Angeles, CA

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Enroll In A Medicare Advantage Plan

Another option is to enroll in a Medicare Advantage plan, sometimes referred to as Medicare Part C. Theyre very popular. The Kaiser Family Foundation reported that 36 percent of Medicare beneficiaries approximately 24.1 million people are enrolled in Medicare Advantage plans.

Medicare Advantage plans are offered by private insurance companies and bundle your Part A and Part B benefits together. Most plans also offer prescription drug coverage and other services as well. Medicare Part C plans often cover items and services that Original Medicare doesnt, such as dental care, hearing aids, and glasses.

Your Medicare Advantage plan will cover the Shingrix vaccine only if you select a plan that offers prescription drug coverage.

In terms of cost, Medicare Advantage plans can be quite affordable. The average monthly premium is just $25, but many plans have $0 premiums. That cost is on top of your Medicare Part B premium. According to the Centers for Medicare & Medicaid Services, the standard monthly premium for Medicare Part B enrollees is $144.60 for 2020.

You can use the Medicare Plan Finder to view available plans, compare coverage options, and see plan pricing so you can enroll in the right Medicare plan for you.

How Much Does The Shingles Vaccine Cost

Depending on your payment source, your cost and coverage for the shingles vaccine can vary. There are costs associated with the vaccine and its administration. Vaccines can be given at a pharmacy, doctors office, or clinic.

If you use your insurance coverage, the least expensive option is typically an in-network pharmacy. If you have an annual deductible for your prescription drug coverage, consider getting both doses of the vaccine within the same calendar year.

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Why Is This New Vaccine More Effective

Infectious disease specialist Dr. Lynora Saxinger says after reading preliminary papers on the Shingrix vaccine, she was very impressed.

“It genuinely is a big step up in vaccinating against varicella-zoster virus . It has much higher rates of protection that seems to not matter how old you are,” Saxinger tells The Current‘s Anna Maria Tremonti.

That is not the case with the older shingles vaccine Zostavax, she argues. While it is decent at reducing risk, it would depend on age on how well a patient would be protected. The vaccine does not respond well to an older immune system, says Dr. Saxinger, highlighting this as a real problem given the elderly are at a higher risk of contracting shingles.

“This actually kind of gives the 80-year-old the immune system of a 20-year-old,” says Dr. Saxinger.

“It seems to provide potentially long-lasting immunity, at least so far it doesn’t seem to decline over the first few years the way the other vaccine did.”

About The Shingles Vaccine

The Centers for Disease Control and Prevention recommends that healthy adults over the age of 50 get the shingles vaccine because it’s the only way to protect against the disease and its associated side effects. The risk of getting shingles increases as you age or if you have a weakened immune system. Always consult your doctor to find out if the shingles vaccine is right for you.

The CDC recommended vaccine, Shingrix, is a recombinant zoster vaccine that has two doses administered within six months of each other. It’s classified as a Tier 3 drug by most insurance companies, which means it’s a brand-name pharmaceutical with a higher copayment than a Tier 1 or 2 drug.

Use the Shingrix vaccine locator to find where the shingles vaccine is being offered, and check with your Medicare Part D or Medicare Advantage provider to see which locations give you the lowest price.

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Who Should Not Get The Shingles Vaccine

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.

What Everyone Should Know About The Shingles Vaccine

Shingles vaccination is the only way to protect against shingles and postherpetic neuralgia , the most common complication from shingles. CDC recommends that healthy adults 50 years and older get two doses of the shingles vaccine called Shingrix , separated by 2 to 6 months, to prevent shingles and the complications from the disease. Your doctor or pharmacist can give you Shingrix as a shot in your upper arm.

Shingrix provides strong protection against shingles and PHN. Two doses of Shingrix is more than 90% effective at preventing shingles and PHN. Protection stays above 85% for at least the first four years after you get vaccinated.

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Who Should Not Get Shingrix

You should not get Shingrix if you:

• have ever had a severe allergic reaction to any component of the vaccine or after a dose of Shingrix
• tested negative for immunity to varicella zoster virus. If you test negative, you should get chickenpox vaccine.
• currently have shingles
• currently are pregnant or breastfeeding. Women who are pregnant or breastfeeding should wait to get Shingrix.

If you have a minor acute illness, such as a cold, you may get Shingrix. But if you have a moderate or severe acute illness, you should usually wait until you recover before getting the vaccine. This includes anyone with a temperature of 101.3°F or higher.

The side effects of the Shingrix are temporary, and usually last 2 to 3 days. While you may experience pain for a few days after getting Shingrix, the pain will be less severe than having shingles and the complications from the disease.

Bcbsil Approves Coverage Of New Shingles Vaccine Shingrix

Blue Cross and Blue Shield of Illinois now covers Shingrix, a new two-dose vaccine approved by the U.S. Food and Drug Administration in October 2017, for reducing shingles and related nerve pain. Until recently, the only vaccine available for shingles was Zostavax, which is 51 percent effective. Clinical trials show Shingrix is 91 percent effective.

For immunocompetent adults ages 50 and older, the Advisory Committee on Immunization Practices recommends Shingrix over Zostavax.1 They also recommend that immunocompetent adults who have already had Zostavax also get Shingrix.1

BCBSIL covers two doses of Shingrix administered to patients ages 50 and older, even if they have already received Zostavax based on current ACIP recommendations. It is important to check eligibility and benefits information to confirm details regarding copays, coinsurance and deductibles before administering this vaccine to BCBSIL members. Checking eligibility and benefits electronically through AvailityTM, or your preferred vendor portal, is strongly encouraged.

*Zostavax and Shingrix prescribing information

For more information on Shingrix, see the Centers for Disease Control and Preventions . Refer to the FDA-approved prescribing information for Shingrix.

This information does not apply to HMO member claims.

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Why Doesn’t Medicare Cover The Shingles Vaccine As Free For All Seniors

Many people think that a vaccine that’s recommended by the CDC for those over age 50 would be fully covered by Original Medicare. However, there are a few reasons why you may end up paying hundreds of dollars for the two-dose regimen.

• Medicare coverage levels: Some Medicare drug plans have better cost-sharing benefits than others, and how much you pay for the shingles vaccine will depend on the plan you choose.
• Pharmaceutical classification: Medicare classifies the Shingrix vaccine as a part of its pharmaceutical coverage, meaning it would fall under Medicare Part D coverage rather than Part A or Part B. In contrast, most private health insurance, either through an employer or through the marketplace, classifies the shingles vaccine as a part of its free preventative coverage.
• Type of pharmaceutical: Shingrix is a Tier 3 drug made by GlaxoSmithKline, and there isn’t a generic alternative. This could mean that your out-of-pocket costs are higher than other medications.

Vaccines For Children Program

Under the VFC program, the Center for Disease Control purchases vaccines at a discount and distributes them to grantees, such as state health departments and certain local and territorial public health agencies. These grantees distribute the vaccines at no charge to private physicians’ offices and public health clinics that are registered as VFC providers. Because the federal government pays for the vaccine, providers are not paid for the cost of the vaccine product. Instead, they are paid an administration fee for the costs that the provider incurs in administering the vaccine. For children enrolled in Medicaid, the Medicaid program pays the vaccine administration fee. For uninsured and underinsured children enrolled in VFC, the parents are billed for the administration fee. The administration fee varies by state.

For additional information regarding vaccines for children, visit the CDC Vaccines for Children.

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Getting The Shingles Vaccine

The Shingrix vaccine is produced by GlaxoSmithKline and approved by the Food and Drug Administration for the prevention of shingles in adults 50 and older. The vaccine is administered in two doses, with the second shot given two to six months after you receive the first shot.

The shot works by boosting your bodys defenses against shingles. In clinical trials, Shingrix was 90 percent effective in preventing shingles.

You can get the Shingrix vaccine at the doctors office or a retail pharmacy with a prescription. Its administered as an injection in the upper arm. After the shot, you may experience pain, redness, or swelling at the injection site as well as muscle pain, tiredness, or headaches.

You must get the second dose two to six months after the first shot. You can sign up for second-dose reminders through the Shingrix website to help keep you on track.

Flu Vaccines Available At Pharmacies

EmblemHealth members ages 18 and over can save time by getting their flu vaccine at a local pharmacy. These pharmacies may be able to provide you with vaccine appointments more quickly and conveniently than your doctors office. Be sure to call ahead to make sure your pharmacy is giving flu shots and to make an appointment.

A pharmacist cannot administer vaccines to children in the State of New York. If your child needs a vaccination, you will need to call your doctor.

Flu vaccines are free for most members.

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Can You Get Shingles If You Had The Chickenpox Vaccine

It depends. Anyone who has ever had chickenpox is susceptible to shingles. When the chickenpox virus comes out of hiding and reactivates, it causes numbness, tingling, blisters, and sometimes flu-like symptoms. If you never had chickenpox because you were vaccinated, you run a very low risk of getting shingles.

Shingles Medicare Billing Problems

Heres a quick reminder about a billing issue that we commonly resolve for our clients. Many doctors continue to bill this to Medicare Part B, and then the bill gets rejected. Once the rejection happens, far too many Medicare beneficiaries just pay these bills without questioning them. One client remembered that our Client Service Team provides FREE help resolving bills like these and called us for support.

Her doctors office had tried to bill her $710 for this medication which is ridiculous! The shingles vaccine costs between $150 $300, and if your Part D plan is covering part of the cost, even less. So, please dont pay any medical bills that you receive without checking with us first.

Do you have questions about which Medicare plans will cover the shingles vaccine? Or perhaps you need help finding a drug plan that includes other vaccines covered by Medicare Part D? Give us a call.

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Can You Get The Shingles Vaccine For Free

The shingles vaccine is manufactured by GlaxoSmithKline Biologicals, a pharmaceutical company. GSK has a patient assistance program that may provide the vaccine to you at no cost if you meet these eligibility criteria:

• You dont have prescription drug coverage or a Part D plan and have spent at least $600 during the calendar year.
• You are an adult, 19 or older.
• You live in the U.S., Puerto Rico, or the District of Columbia.
• You dont qualify for Puerto Ricos Government Health Plan.
• Your maximum monthly gross income does not exceed certain limits, depending on where you reside and your household size.
• You apply through your health care provider, who will register for the patient assistance program and submit your application.

Medicare May Not Provide Good Coverage For This Vital Protection

If you’re covered by Medicare, you may feel the pain of a shingles shot more in your wallet than in your arm.

That’s because the federal program that insures most seniors in the U.S. provides poor coverage for some recommended vaccines, including shingles, and could leave some people paying $200 or more for protection.

Shingles is a viral infection that often causes a painful, blistering rash and, in some cases, leads to lingering nerve pain and, in rare cases, even blindness.

The vaccine isn’t foolproof, but for people aged 60 and older it reduces the risk of getting shingles by about 51 percent and, if you do get shingles, reduces the nerve pain it causes by close to 70 percent, according to the Centers for Disease Control and Prevention.

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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.

Get Medicare Part D Coverage

Medicare Part D is an optional benefit you can get if you are enrolled in Medicare. With Medicare Part D, you can get coverage for prescription drugs. Depending on your plan, Medicare Part D may cover both brand-name and generic medication.

Medicare Part D plans cover all commercially available vaccines, including Shingrix. By purchasing Medicare Part D, you can get coverage for the shingles vaccine.

According to the Kaiser Family Foundation, the average monthly premium for Medicare Part D was $40 in 2019. However, youll likely have to pay a copayment when you get your shots, too.

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