Shingles, a painful skin rash caused by the reactivation of the varicella-zoster virus (the same virus that causes chickenpox), can have severe complications, especially for older adults. The Shingrix vaccine, approved by the FDA in 2017, offers strong protection against shingles and its complications. However, understanding whether Medicare Part D covers Shingrix can be complex. This article aims to clarify Medicare Part D coverage for the Shingrix vaccine, exploring eligibility, costs, and related considerations.
Overview of Shingles and the Shingrix Vaccine
Shingles is characterized by a painful rash that can appear anywhere on the body, often forming a stripe of blisters on one side of the torso. The condition can lead to postherpetic neuralgia (PHN), a severe pain in the areas where the shingles rash occurred, persisting even after the rash disappears. The risk of shingles and PHN increases with age, making vaccination crucial for older adults.
Shingrix, a recombinant zoster vaccine, has been shown to be over 90% effective at preventing shingles and PHN. It is recommended for adults aged 50 and older, administered in two doses with a two to six-month interval between doses. Given its effectiveness, many older adults seek to get vaccinated but often have questions about coverage under Medicare.
SEE ALSO: What is Disseminated Shingles?
Medicare and Vaccine Coverage: An Overview
Medicare, the federal health insurance program for people aged 65 and older, as well as certain younger individuals with disabilities, provides coverage through different parts:
- Medicare Part A (Hospital Insurance): Covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
- Medicare Part B (Medical Insurance): Covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
- Medicare Part C (Medicare Advantage): An alternative to Original Medicare, provided by private companies approved by Medicare, often includes additional benefits.
- Medicare Part D (Prescription Drug Coverage): Adds prescription drug coverage to Original Medicare and some Medicare Cost Plans, Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.
Coverage of Shingrix Under Medicare Part D
Medicare Part D is the primary part of Medicare that covers prescription medications, including vaccines not covered by Medicare Part B. While Medicare Part B covers vaccines such as the flu shot, pneumococcal vaccines, and hepatitis B for medium to high-risk patients, Shingrix falls under the purview of Medicare Part D.
Eligibility for Shingrix Under Part D
To receive coverage for Shingrix under Medicare Part D, beneficiaries need to be enrolled in a Medicare Part D plan or a Medicare Advantage plan that includes Part D benefits. Each Part D plan has its formulary, a list of covered drugs and vaccines. Shingrix is typically included in these formularies, but specific coverage details, such as copayments and prior authorizations, can vary.
Cost Considerations
The cost of Shingrix under Medicare Part D depends on several factors, including the plan’s formulary, the beneficiary’s pharmacy choice, and their specific Part D plan’s cost-sharing structure. Here’s a breakdown of potential costs:
1. Deductibles: Some Part D plans have an annual deductible that must be met before the plan starts to pay its share of covered medications, including vaccines. The deductible amount can vary widely between plans.
2. Copayments and Coinsurance: After meeting the deductible, beneficiaries typically pay a copayment or coinsurance for each dose of Shingrix. This amount can differ based on the tier placement of Shingrix in the plan’s formulary.
3. Out-of-Pocket Maximums: Medicare Part D includes an out-of-pocket threshold, after which catastrophic coverage kicks in. Once beneficiaries reach this threshold, they pay significantly reduced copayments or coinsurance for covered drugs, including Shingrix.
Coverage During Different Phases
Medicare Part D plans often have different phases of coverage, affecting the cost of Shingrix:
1. Initial Coverage Phase: After meeting the deductible, beneficiaries pay copayments or coinsurance until their total drug costs reach a certain limit.
2. Coverage Gap (Donut Hole): Once total drug costs reach the initial coverage limit, beneficiaries enter the coverage gap, during which they may pay higher out-of-pocket costs for drugs. However, due to recent changes, beneficiaries now receive a discount on brand-name drugs and a smaller discount on generics while in the coverage gap.
3. Catastrophic Coverage Phase: After out-of-pocket costs reach the catastrophic coverage threshold, beneficiaries pay significantly lower copayments or coinsurance for the remainder of the year.
How to Determine Coverage for Shingrix
Beneficiaries should take the following steps to determine if their Medicare Part D plan covers Shingrix and understand their potential costs:
- Review the Formulary: Check the plan’s formulary to see if Shingrix is listed and under which tier it falls. This information is often available on the plan’s website or can be obtained by calling the plan’s customer service.
- Check for Prior Authorization Requirements: Some plans may require prior authorization for Shingrix, meaning the beneficiary or their doctor must obtain approval from the plan before the vaccine is covered.
- Compare Costs at Different Pharmacies: Medicare Part D plans often have preferred and non-preferred pharmacy networks. Using a preferred pharmacy can result in lower out-of-pocket costs for vaccines and medications.
- Consult the Plan’s Annual Notice of Change (ANOC): Each year, Part D plans send an ANOC to enrollees, detailing any changes in coverage, including changes to the formulary and cost-sharing requirements. Reviewing this document can help beneficiaries stay informed about their plan’s coverage for Shingrix.
Additional Considerations for Medicare Advantage Plans
Medicare Advantage plans, also known as Medicare Part C, are an alternative to Original Medicare offered by private insurance companies. These plans often include prescription drug coverage (MAPD plans). Beneficiaries enrolled in a Medicare Advantage plan should review their plan’s benefits to understand coverage for Shingrix, as it can differ from the coverage provided by standalone Medicare Part D plans.
Advantages of Medicare Advantage Plans
Medicare Advantage plans can offer additional benefits not covered by Original Medicare, such as vision, dental, and hearing services. These plans might also have different cost structures and network requirements that could impact the cost and accessibility of the Shingrix vaccine.
Network Restrictions
Medicare Advantage plans often require beneficiaries to use healthcare providers and pharmacies within their network. Getting the Shingrix vaccine at an out-of-network provider might result in higher out-of-pocket costs or no coverage at all. Therefore, it’s essential to check if the vaccine is covered within the plan’s network.
Conclusion
Understanding Medicare Part D coverage for the Shingrix vaccine involves navigating plan formularies, cost-sharing structures, and potential coverage phases. For most beneficiaries, Shingrix is covered under Medicare Part D, but out-of-pocket costs can vary based on individual plan details. By reviewing their plan’s formulary, understanding cost-sharing requirements, and choosing in-network pharmacies, beneficiaries can effectively manage their healthcare and ensure they receive the necessary protection against shingles.
The high effectiveness of Shingrix in preventing shingles and its complications makes it a valuable vaccine for older adults. Ensuring coverage under Medicare Part D helps make this protection more accessible. Beneficiaries should proactively review their Medicare Part D plan details and consult with their healthcare providers to stay informed about their vaccine coverage and make the best decisions for their health.
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