Shingles Shot
Shingrix is a Tier 3 (Preferred Brand) drug with no restrictions on the Medicare formularies. Shingrix is NOT payable under Part B and is covered by Part D. If the vaccination is given in a physician’s office, the member will pay the provider the cost of the drug and administration fee and will subsequently need to submit reimbursement through Part D.
We recommend members get this vaccine at the pharmacy to ensure their lowest out-of-pocket expense.
At the physician’s office:
Members can receive their Part D vaccines at their doctor’s office. In this case, they may have to pay for the services upfront and submit their receipt for reimbursement. BCBSM will reimburse up to our approved amount less the applicable vaccine copay/coinsurance. The Part D plan will cover the vaccination itself and for the administration of the vaccine.
Regarding administration, per CMS:
TRHCA modified the definition of a Part D drug to include “for [Part D] vaccines administered on or after January 1, 2008, its administration.” Consequently, beginning on January 1, 2008, the Part D program will cover vaccine administration costs associated with Part D vaccines. Thus, the coverage available in 2007 under Part B will cease and reimbursement will be available solely under Part D. CMS interprets this new statutory requirement to mean that the Part D vaccine administration costs are a component of the negotiated price for a Part D-covered vaccine. In other words, the negotiated price for a Part D vaccine will be comprised of the vaccine ingredient cost, a dispensing fee (if applicable), sales tax (if applicable), and a vaccine administration fee. This interpretation recognizes the intrinsic linkage that exists between the vaccine and its corresponding administration, since a beneficiary would never purchase a vaccine without the expectation that it would be administered.