QUESTION: What is the difference between vaccines and pricing?

Immunizations are covered by different parts of your Medicare coverage. You mentioned the flu shot first, so I will start with that. The flu shot, along with the pneumococcal vaccine are covered under Original Medicare Part B. Both of these vaccines have been around a long time, before Prescription Drug coverage was required. Both of these vaccines are free under Medicare and most Medicare Advantage Plans. You may find that in some situations you are charged a fee for the administration of the vaccine. We often see walk-in clinics for these types of vaccines. You can also receive these vaccines in your doctor’s office.

The flu vaccine is a yearly immunization if you choose to get it. The Pneumococcal vaccine has two different versions and you should work with your physician about when and why it is appropriate for you.

The Shingles vaccine now comes in two different versions. This vaccine is handled very differently than the flu and pneumococcal immunizations that we just reviewed. The Zostavax & Shingrix immunizations are billed through Medicare Part D, NOT Medicare B. For these immunizations, you must get a prescription/order from your doctor’s office. Then you get the vaccine from your pharmacy, and it is covered under your prescription drug coverage benefit. When you have Medicare, your vaccine is billed to your Medicare Part D plan. If you have a Medicare Advantage (MA) Plan that includes prescription drug coverage, the vaccines will be covered under the Prescription Drug benefit of your MA plan.

The Zostavax & Shingrix vaccine is administered by the pharmacists at the local pharmacy. The Zostavax is a single vaccine and is not as popular as it once was. The Shingrix vaccine is actually two vaccines administered with significant time between the vaccines.

These vaccines can be very expensive. All Medicare Part D plans cover the vaccines, but there can be significant differences in the cost. Many of the plans require a prior approval before getting the vaccine. Your co-pay for the vaccine itself will vary depending on where you are in your Part D Coverage (deductible, initial coverage, coverage gap or catastrophic coverage). You must contact your plan, or your pharmacy can check on how much it will cost you.

When doing research for this article, I found that (as mentioned) all the Medicare Part D plans cover both of the vaccines, but the cost can be VERY different. You may have a charge of an administration fee (usually $20). This is paid where you have the vaccine done.

For those individuals with a Part D deductible you would pay full price which ranged about $250 for Zostavax and about $150 for each of the two Shingrix vaccines (each plan is a little different). Without a deductible or those who already met the deductible, the co-pays for the vaccine ranged from $35 to over $100. For most of the Part D plans these vaccines are a Tier 3 medication cost structure.

For those individuals in the coverage gap of their Medicare Part D plan, the cost would be 25% of the negotiated cost for your plan. These pricing differences make the vaccines more difficult and complicated to understand.

These vaccines are certainly easier to get now than they were a few years ago. So no matter what your age, you can get this vaccine, if you and your physician feel it is appropriate. As with any medical treatment, your primary concern should not be the cost, it should be “Is this appropriate for me?” (There are some situations and medical conditions where the vaccine is NOT recommended.) Then consider the cost in your decision to go through with it.