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Why Does My Shingles Vaccine Cost So Much?
If you’re covered by Medicare, you may feel the pain of a shingles shot more in your wallet than in your arm.
Prompted by a reader question on why she had to pay so much money for this vital vaccine, we took a closer look at how much it costs. Turns out that the federal program that insures most seniors in the U.S. provides poor coverage on some recommended vaccines. That leaves some older people paying nearly $200 for protection against shingles, a viral infection that often causes a painful, blistering rash and, in some cases, leads to lingering nerve pain and rarely even blindness.
The vaccine isn’t perfect, but for people aged 60 and older it reduces the risk of getting shingles by about 51 percent and the nasty nerve pain by close to 70 percent, according to the Centers for Disease Control and Prevention.
Read more about the shingles vaccine and two other immunizations adults need now.
The problem is that unlike the flu and pneumonia vaccines, which are fully covered as a 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. You’ll pay less out of pocket for drugs in tier 1 and 2, which are mainly lower-priced generics and “preferred brand-name” drugs. And you’ll pay more for expensive, “nonpreferred brands” in tier 3 or 4. The most expensive drugs are usually grouped into tier 5.
And, you guessed it, we found that many Part D plans categorize the shingles vaccine, Zostavax, as an expensive tier 3 or 4 drug. Only one company, Merck, makes the shingles shot and there’s currently no generic version.
That means if you haven’t met your annual deductible, you’ll likely wind up paying full price for the shot—around $190. But even after the deductible, depending on your plan, we found that consumers may have to pay a significant part of the shingles vaccine cost, up to $100.
To make matters worse, many healthcare providers haven’t set up billing systems to file claims through prescription drug plans. So if you are vaccinated at your doctor’s office, you could have to pay the full shingles vaccine cost up front and then file to be reimbursed by your insurance.
Other Types of Plans Do Better
Other forms of insurance do a much better job covering immunizations. Under provisions of the Affordable Care Act (a.k.a. “Obamacare”), private plans, such as insurance you have through your employer or purchased on a state marketplace, are required to cover recommended vaccinations as preventive medical care, not drugs. That means, as long as you go to a provider in your plan’s network, your insurance will pay for preventive care without a co-pay—even if you haven’t met your deductible.
“It’s really a shame that older Americans, who are most at risk of contracting shingles and most vulnerable to the potentially serious effects of the disease, often have to pay more than others for the vaccine,” says Consumer Reports’ Medical Director Orly Avitzur, M.D.
If you’re currently covered by a private health plan, but anticipate going on Medicare in the next five years or so, one cost-saving strategy is to talk to your doctor about updating all your vaccinations now while your insurance provides good coverage, says Avitzur. The shingles shot is recommended for nearly all adults aged 60 and older.
Don’t Overpay: Advice for Medicare Patients
Three out of four Americans eligible for the shingles vaccination still haven’t gotten it, according to the CDC. Not surprisingly, a 2015 report from the agency found that one of the main reasons adults skip recommended vaccines is the cost.
If you’ve been putting off getting your shingles shot because you were quoted a high price, check with your Part D plan: You may be able to get it for less.
“Confusion about insurance coverage for the vaccine can sometimes result in patients paying more than they should,” says Avitzur.
In fact, now is perfect time to get vaccinated because you’ve likely met your plan deductible for the year.
“Don’t delay as the consequences of shingles can be devastating,” advises Avitzur, who as a neurologist has seen first hand the painful effects of lingering nerve damage.
Your best bet may be to get the shot at a pharmacy in your drug plan’s network. You’ll still need to get a prescription from your doctor, but the pharmacy will bill your insurance company and you’ll pay the lowest out-of-pocket costs available under your plan.
If you would like to get vaccinated at your doctor’s office, ask upfront about cost. Does your doctor charge more to administer the shot than your plan allows? If so, you’ll be on the hook for the difference. Also, see if the office will bill your Part D or Medicare Advantage plan directly, or work with a pharmacy in your network to handle the billing.
Finally, if you don’t have health insurance or are experiencing medical or financial hardship, you may qualify for Merck’s Vaccine Patient Assistance Program, which provides free vaccinations to those who are eligible. For details see www.merckhelps.com.
Consumer Reports has no relationship with any advertisers on this website. Copyright © 2006-2015 Consumers Union of U.S.
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