To the Editor: In their 1-Minute Consult, Drs. Singh and Englund give a thorough review of Zostavax, the vaccine to prevent shingles. 1 Unfortunately, the information they provided on cost and reimbursement is incomplete.
As they noted, this vaccine is not covered by Medicare part B and is mandated to be covered by Medicare part D as a “prescription drug.” Furthermore, the vaccine administration charge cannot be billed to Medicare part B. Since physician offices do not bill prescription drug plans, physicians are permitted to administer the vaccine, charge the patient for the vaccine and administration, and have the patient submit the receipt to his or her prescription drug provider for reimbursement. There is no fee schedule for this vaccine, so physicians are free to charge a fee that they deem reasonable. For patients without part D, it is reasonable to ask them to call their prescription provider and inquire about coverage before vaccination, since many commercial plans will not cover the vaccine, and the $200 or more price may be unaffordable for many.
Alternatively, physician offices may enroll with a private vendor, eDispense Vaccine Manager, at enroll.edispense.com, and submit charges for Zostavax electronically to the patient’s Medicare part D provider; eDispense is contracted with most of the large part D providers. This service allows the physician to input the patient’s demographics and get an immediate response, showing the patient’s coverage and copayment, and allowing the physician to submit the claim electronically. There is no charge to the physician, and the reimbursement covers the cost of the vaccine, the administration cost, and a small profit. If the patient wishes to pay for the vaccine, the system can produce a receipt containing all the information needed for submission by the patient to the insurer. (Note: I have no financial or ownership interest in eDispense.com or Merck.)
Since recommending and administering Zostavax is soon to become the standard of care, the availability of these options will provide better care than the authors’ recommendation that patients pick up the vaccine and transport it back to the physician’s office on ice, which risks defrosting and inactivating the vaccine, or leaving patients to find a vaccine provider on their own.