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What to know about getting the shingles vaccine at the doctor’s office

During Irene’s annual Medicare wellness visit, her physician asked whether she ever had chickenpox. Yes, she replied, at age 7. Because she had chickenpox, her physician knows she’s at greater risk for shingles. He recommended that Irene get the shingles vaccine right away, in his office. What should Irene do?

All Medicare Part D prescription drug plans, whether a stand-alone plan or one that’s part of a Medicare Advantage plan, cover all commercially available vaccines as long as the vaccine is reasonable and necessary to prevent illness. Zostavax has been available since 2006. Shingrix was approved in 2018.

Drug plans can treat these medications differently, which will have an impact on how much a person must pay out-of-pocket. The drugs are generally either a Tier 3 or Tier 4. 

The most cost-effective and easiest option for Irene is not necessarily the most convenient one. She should head to the nearest pharmacy that is in her Part D prescription drug plan’s network. The pharmacy will charge Irene the copayment for the vaccine (the amount depends on the tier of the drug) and bill the drug plan directly for the vaccination.

If Irene wants to get the vaccine in the physician’s office, she needs to ask some questions. Does the office work with a pharmacy that can bill Irene’s drug plan for the entire cost of the vaccination (the vaccine plus an administration or dispensing fee)?  Or, can the doctor bill your plan directly through its computer billing process?

If not, Irene likely will have to pay the entire cost of the vaccination up front. Here’s why...  A physician’s office is considered out of network when it comes to medications. That’s simply because it is an office, not a pharmacy, and it has not signed a contract with the Part D plan. The physician would administer the vaccine and one way to handle the cost would be to bill Irene for the entire charge (the vaccine and an administration or dispensing fee). She will have to submit a paper claim requesting reimbursement for the charges, not the easiest thing to do because each drug plan has its own procedure and paperwork. Irene may have to get help from the physician’s billing staff to complete this paperwork.  

Last updated: 05-22-2019