Have Medicare? The shingles vaccine will cost you

Philly.com

Nov. 29--When Stanley Isenberg learned there was a new shingles vaccine, he set out to find it.

His father had gotten shingles, a painful, blistered rash, and he wanted to avoid that fate at all costs.

Isenberg, a 94-year-old World War II veteran was prepared to pay. But he was still shell-shocked by the price the pharmacist quoted: $167.

"I said, 'Wow!'" Isenberg recalled.

The pharmacist shrugged. Isenberg chewed on the number, thought about his father, then rolled up his sleeve and replied, "Let's go."

Shingrix, a two-shot shingles vaccine by GlaxoSmithKline, has been in such high demand since it was released last year that many pharmacies have had a hard time keeping it in stock. But if you're lucky enough to track down a dose and are covered by Medicare, be prepared to pay dearly.

Under the Affordable Care Act, most private insurance plans are required to cover the vaccine at no additional cost to members.

But for Medicare beneficiaries, the cost will vary depending on what type of drug coverage you have. People with traditional Medicare may purchase a separate Part D drug plan, while Medicare Advantage plans sold by private insurers typically include prescription coverage. Each plan will cover the vaccine differently. You may have a copay to get the vaccine and an additional fee if you haven't yet met your deductible. Because you need two shots, you'll pay twice.

"The prices are all over the map," said Sue Greeno, a Medicare advocate with the Center for Medicare Advocacy in Washington, D.C. "I strongly advise people if they're considering this to check with their plan if it's on their covered list of drugs."

The U.S. Centers for Disease Control and Prevention recommends everyone over age 50 who had chickenpox get two doses of Shingrix. The vaccine is 97 percent effective in preventing shingles among people aged 50 to 69.

People should get Shingrix even if they already received Zostavax, an earlier and much less effective shingles vaccine made by Merck.

The CDC recommends getting the second shot between two and six months after the first. If you're not able to get the second shot in that window, get it as soon as you can — you won't have to start the regimen over, according to the CDC. Use the website www.vaccinefinder.org if it's out of stock at your regular pharmacy.

‘Why so expensive?’

Demand for the vaccine has exceeded expectations and left GSK scrambling to ramp up production.

GSK distributed as many doses in July, August and September as it did in the entire first half of the year. As of September, nearly 7 million doses of Shingrix have been administered globally since it was released in November 2017, according to the company. The majority of those doses were in the U.S., where Shingrix became available in June.

GSK is working on shortening the vaccine's production time — currently between six and nine months — to get more of it to pharmacies. Over the next few years, the company expects to supply doses "in the high teens millions" annually, said Sean Clements, a GSK spokesperson, in a statement.

"We understand that this is a challenging situation to manage and GSK is fully committed to expediting Shingrix resupply," Clements said.

Before turning to the pharmacy in August, Isenberg tried to get the vaccine at the Philadelphia VA Medical Center, but they were all out.

When he was due for his second shot, Isenberg first returned to the pharmacy where he'd gotten his first dose but they didn't have it. Next, he tried a different VA medical center, closer to his new home in Audubon, Pa.

He was in luck!

"The doctor said, 'We have the vaccine and your time is now, so roll up your sleeve,'" Isenberg said.

Veterans receive the shingles vaccine at no cost at VA medical centers, the agency said.

Isenberg said he had been willing to fork over $167 for the first shot and was prepared to pay for the second because he knows it's important. Still, the no-charge shot from the VA medical center was a relief.

"Why? Why so expensive?" Isenberg said.

The shortages, the vaccine's high efficacy and the fact that Shingrix is a brand-name drug with no competitors have all contributed to its price tag, said Thomas Goetz, chief of research at GoodRx, an online drug price comparison tool.

"It's not an incremental improvement — it's a material difference, in terms of efficacy. There's a market for that and there's one manufacturer, so they can put their price on it. They hold a lot of cards in the negotiations with insurers," Goetz said.

Cost varies greatly

Shingrix is covered by more than 90 percent of private insurance and Medicare drug plans. The vast majority of people with private insurance who get the vaccine at an in-network pharmacy have an out-of-pocket cost of no more than $10, according to GSK.

Even though the drug is covered by Medicare, members' out-of-pocket cost can vary greatly from one plan to the next.

"For other services like hospitalizations or doctor services, Medicare has a price it's willing to pay that's often lower than what we might see in the non-Medicare private commercial market," said Juliette Cubanski, associate director of the Kaiser Family Foundation's program on Medicare policy.

That's not the case for prescription medications, which aren't covered by traditional Medicare. Standalone drug plans and Medicare Advantage plans that include drug benefits all negotiate prices for medications individually. The federal government can dictate which drugs must be included in drug formularies, but it is up to the insurers that sell those plans to decide how much to charge, she said.

According to GoodRx, Medicare members pay anywhere from zero dollars to $153 for each Shingrix shot. The retail price is about $180 per shot.

"That's a huge range, and that's where people get especially frustrated. Their friends or neighbors may be getting the vaccine for little to nothing, whereas their Part D is hitting them up with a copay," Goetz said.

He recommends checking with your plan in advance to find out how much to expect to pay for the shot and compare the price at different pharmacies. Prices can vary by pharmacy, too.

If the cost will be significant, find out whether you qualify for financial assistance.

People with private insurance and incomes less than 250 percent the federal poverty level can qualify for GSK's patient assistance program.

Medicare beneficiaries must also have spent $600 out of pocket on medications to qualify for the assistance program, in addition to meeting income requirements.

Other Medicare discount programs funded by the federal government and states can also help cover medication and premium costs, Greeno said. Contact Medicare or your local health department to find out if you're eligible for a Medicare Savings Program.

Medicare's annual enrollment period — which runs through Dec. 7 — is an opportunity for seniors to review their coverage, learn about any changes to their current plan and make sure it still meets their needs. That includes checking that the medications you take will still be covered, since the list of drugs covered by a plan can change from one year to the next.

Check too how the plan will cover Shingrix, if you haven't gotten the vaccine yet. People are less likely to think of a vaccine than the medications they take daily when evaluating drug costs, but depending on the plan you choose, how Shingrix is covered could make a big difference in your total out-of-pocket cost, Greeno said.

"People often shop for plans based on the plan name, but they don't realize that's much less important than what kind of out-of-pocket costs they're going to have," she said.

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