Reimbursement for Shingrix, the new zoster vaccine | 90750

At the end of 2017, there was news that a new vaccine for shingles, Shingrix, was significantly more effective than the older vaccine, Zostavax.  The new vaccine was recommended in place of the old, and for patients who had already received the older vaccine.  An article in The New York Times summarized the benefits.

The CPT^® code for Shingrix is 90750, and of course, there is only one ICD-10 code to remember for immunizations, Z23.  The patient needs two doses, separated by at least 2 months.

Coverage for shingles vaccine

Original Medicare doesn’t pay for this immunization under Part A or Part B.  That means, medical practice can’t give it to Medicare patients and be reimbursed for it.

The CMS website says

“Generally, Medicare prescription drug plans (Part D) cover all commercially-available vaccines.”

Patients with original Medicare will need to check their coverage and go to the pharmacy for the service. The cost to the patient will depend on the patient’s Part D coverage.  The Part D plan is not required to pay if in full, although the patient may receive a negotiated rate. For Medicare Advantage, check with your plan.

Commercial policies that are compliant with the Affordable Care Act (ACA) preventive coverage will pay for it, based on the recommendation of the Advisory Committee on Immunization Practices. (ACIP).

I checked a few websites, and it seems that Anthem, UnitedHealthcare, and Aetna are covering the vaccine.  It would be prudent to check for coverage before administering the vaccine, especially as patients purchase non-ACA plans.

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