ZOSTAVAX is a live attenuated virus vaccine indicated for prevention of herpes zoster (shingles) in individuals 50 years of age and older. ZOSTAVAX is not indicated for the treatment of zoster or postherpetic neuralgia. ZOSTAVAX should not be used for prevention of primary varicella infection (Chickenpox).

Reimbursement for Practice and Pharmacy

Coverage for Commercially Insured and Medicare Part D Patients

Patients aged ≥50 years may be covered for administration of ZOSTAVAX at the pharmacy3

Vaccinate private insurance patients in office or send them to a vaccinating pharmacy.
For patients with commercial insurance coverage, there may be different options available for reimbursement:

  1. Pharmacy Benefit Manager (PBM)
    Adjudicate claims using a patient’s Pharmacy Benefit Card.
  2. Medical Benefit
    Adjudicate claims through medical insurance plans, if your pharmacy is part of the plan’s medical services network of pharmacies.
  3. Cash or Health Savings Account (if available)
    Provide patients with a receipt so they can pursue reimbursement with their health plan, at their discretion.

Many of the patients whose plans cover ZOSTAVAX have low or no co-pay3
In fact, as of 2016 ~7 out of 10 patients have less than a $10 co-pay.

Remember: Whether reimbursement is available and the amount of reimbursement for a specific patient depends on the patient’s benefit design, including applicable co-pays, coinsurance, deductibles, and/or limits. You should confirm each patient’s coverage and cost-sharing obligations with the relevant payer. Pharmacy vaccination regulations vary by state and not all pharmacies are able to vaccinate patients.

Coverage for Medicare Part D Patients

Many pharmacists can vaccinate and adjudicate Medicare Part D claims for ZOSTAVAX4,a

100% of Medicare Part D plans have ZOSTAVAX on formulary as of October 2017.b

  1. aRemember: These pages contain suggestions that you may want to consider implementing. Adult vaccination can be approached in different ways and some of the suggestions here may be more relevant for your organization than others. The reimbursement-related information provided here and on the following pages is subject to change and its use is not a guarantee of coverage or payment. As a provider, you are solely responsible for billing payers correctly and for determining if any payer-specific guidelines apply. Merck does not guarantee or assure the timeliness or appropriateness of this information for your particular use given the frequent changes in public and private payer billing.
  2. bFormulary data provided by DR/Decision Resources, LLC, and current as of October 2017. (© DR/Decision Resources, LLC. All Rights Reserved.)

Co-pay Considerations

Up to 1 Out-of-Pocket Payment

May be covered by insurance in the pharmacy. In fact, as of 2016 ~7 out of 10 patients who have commercial insurance in the pharmacy have less than a $10 co-pay.3

CPT® Codes

CPT codes for ZOSTAVAX

90736 (product)

90471 or 90472 (administration)

These CPT codes are effective as of December 2017 as set forth in the Current Procedural Terminology CPT 2017.

CPT=Current Procedural Terminology.
CPT © 2017 American Medical Association. All Rights Reserved.
CPT is a registered trademark of the American Medical Association.

reference3

Reference

  1. Data available on request from Merck, Professional Services-DAP, WP1-27, PO Box 4, West Point, PA 19486-0004. Please specify information package VACC-1203696-0003.
reference4

Reference

  1. Data available on request from Merck, Professional Services-DAP, WP1-27, PO Box 4, West Point, PA 19486-0004. Please specify information package VACC-1114216-0004.

Indication for ZOSTAVAX

ZOSTAVAX® (Zoster Vaccine Live) is a live attenuated virus vaccine indicated for prevention of herpes zoster (shingles) in individuals 50 years of age and older. ZOSTAVAX is not indicated for the treatment of zoster or postherpetic neuralgia. ZOSTAVAX should not be used for prevention of primary varicella infection (Chickenpox).

Vaccination with ZOSTAVAX® (Zoster Vaccine Live) does not result in protection of all vaccine recipients.
Do not administer ZOSTAVAX to individuals who are immunodeficient or immunosuppressed due to disease or therapy, as serious or fatal disseminated vaccine strain varicella-zoster virus disease may occur. Causes of immunodeficiency or immunosuppression may include, but are not limited to, primary or acquired immunodeficiency states, AIDS or other clinical manifestations of infection with human immunodeficiency viruses, leukemia, lymphoma or other malignant neoplasms affecting the bone marrow or lymphatic system, and immunosuppressive therapy.

Vaccination with ZOSTAVAX® (Zoster Vaccine Live) does not result in protection of all vaccine recipients.

Do not administer ZOSTAVAX to individuals who are immunodeficient or immunosuppressed due to disease or therapy, as serious or fatal disseminated vaccine strain varicella-zoster virus disease may occur. Causes of immunodeficiency or immunosuppression may include, but are not limited to, primary or acquired immunodeficiency states, AIDS or other clinical manifestations of infection with human immunodeficiency viruses, leukemia, lymphoma or other malignant neoplasms affecting the bone marrow or lymphatic system, and immunosuppressive therapy.

A reduced immune response to ZOSTAVAX was observed in individuals who received concurrent administration of PNEUMOVAX®23 (Pneumococcal Vaccine Polyvalent) and ZOSTAVAX compared with individuals who received these vaccines 4 weeks apart. Consider administration of the two vaccines separated by at least 4 weeks.

Serious vaccine-related adverse reactions that have occurred following vaccination with ZOSTAVAX include asthma exacerbation and polymyalgia rheumatica. Other serious adverse events reported following vaccination with ZOSTAVAX include cardiovascular events (congestive heart failure, pulmonary edema). Common adverse reactions occurring in ≥1% of vaccinated individuals during clinical trials include injection-site reactions (erythema, pain/tenderness, swelling, hematoma, pruritus, warmth) and headache.

Transmission of vaccine virus may occur between vaccinees and susceptible contacts.

Deferral should be considered in acute illness (for example, in the presence of fever) or in patients with active untreated tuberculosis.

Before administering ZOSTAVAX, please read the accompanying Prescribing Information. The Patient Information also is available.

ZOSTAVAX® (Zoster Vaccine Live) is a live attenuated virus vaccine indicated for prevention of herpes zoster (shingles) in individuals 50 years of age and older. ZOSTAVAX is not indicated for the treatment of zoster or postherpetic neuralgia. ZOSTAVAX should not be used for prevention of primary varicella infection (Chickenpox).

US-CIN-00011 12/19