COST & COVERAGE FOR SHINGRIX

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Coverage of SHINGRIX on Selected Plans in:

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What you need to know about this formulary information

Individual access may vary by geography and plan benefit design. Formulary status may vary and is subject to change. Formulary coverage does not imply clinical safety or efficacy. This is not a guarantee of partial or full coverage or payment. Consumers may be responsible for varying out-of-pocket costs based on an individual’s plan and its benefit design. Each plan administrator determines actual benefits and out-of-pocket costs per its plan’s policies. Verify coverage with plan sponsor or Centers for Medicare & Medicaid Services. GSK does not endorse individual plans.

The Advisory Committee on Immunization Practices (ACIP) recommends SHINGRIX for the prevention of herpes zoster and related complications for immunocompetent adults aged ≥50 years.1

SHINGRIX is not indicated for the prevention of herpes zoster-related complications.

Coverage of Adult Vaccines Recommended by the Advisory Committee on Immunization Practices

Medicare Part D: Effective for plan years beginning on or after January 1, 2023, the deductible shall not apply to, and there is no cost sharing for an adult vaccine recommended by the ACIP.2

Commercial: Per the Affordable Care Act (ACA), non-grandfathered group health plans and health insurance issuers are required to cover vaccines when prescribed consistent with ACIP recommendations, and without cost-sharing requirements when the service is delivered by an in-network provider.3

Source: Managed Markets Insight & Technology, LLC, MMIT Database as of 07/25/25.

References:

1. Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep 2018;67:103-108. DOI: http://dx.doi.org/10.15585/mmwr.mm6703a5

2. IRA insulin vaccines memo: contract year 2023 program guidance related to Inflation Reduction Act changes to Part D coverage of vaccines and insulin. Centers for Medicare & Medicaid Services. Accessed June 24, 2023. https://www.cms.gov/files/document/irainsulinvaccinesmemo09262022.pdf

3. Affordable Care Act Implementation FAQs - Set 12. Centers for Medicare & Medicaid Services. Accessed August 23, 2023. https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/aca_implementation_faqs12

SHINGRIX is $0

for most patients ≥50 years old1,2,*

For patients with commercial insurance plans†:

  • 98% of commercial patients pay $0 for SHINGRIX1
  • Average copays are just $4 or less1

For your Medicare Part D patients:

  • Due to the Inflation Reduction Act, Medicare Part D patients can get SHINGRIX for $0 through their pharmacy2
  • *

    Coverage and cost may vary and are subject to change without notice. Reimbursement decisions are made by individual insurance plans.

  • †

    SOURCE: Based on IQVIA data of paid 2023 SHINGRIX claims.

Use the following codes when billing for SHINGRIX

CPT Code (Product)3:

 90750

CPT Code (Adminstration)4

1 vaccine administered

Each additional vaccine administered during same encounter

 

90471

90472

ICD-10-CM Code5 (Encounter for Immunization):

 Z23

MVX Code6:

 SKB

CVX Code7:

 187‡

NDC§ (10-dose carton):

 58160-823-11

Not intended to serve as comprehensive training on medical billing and coding. Users should independently verify accuracy. Healthcare providers are responsible for making the ultimate decision on when to use a specific product based on clinical recommendations and how to bill for products and related services rendered. Consult third-party insurers’ guidelines for specific information regarding the billing and reporting of services rendered.

  • ‡

    The CDC also created CVX code 188 for “zoster vaccine, unspecified formulation” to facilitate transmission of administration data when the exact formulation of the vaccine is not known (such as when recording data from a vaccination card).

  • §

    Where Payer requires an 11-digit NDC, the code would be 58160-0823-11.

  •  

    CDC=Centers for Disease Control and Prevention; CPT=Current Procedural Terminology; CVX=vaccine administered; ICD-10-CM=International Classification of Diseases, 10th Revision, Clinical Modification; MVX=manufacturers of vaccines.

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The GSK Vaccines Reimbursement Support Center is a resource for physicians, physician office staff, and pharmacists to help address questions about billing, coding, and reimbursement for GSK vaccines.

GSK Vaccines Reimbursement Support Center contact information:


Phone: 1-855-636-8291

Fax: 1-877-683-1329

Monday – Friday

8:00 am – 8:00 pm ET

GSK VACCINES REIMBURSEMENT SUPPORT CENTER

Indication & Important Safety Info

Indication

Important Safety Information

Indication

SHINGRIX is a vaccine indicated for prevention of herpes zoster (HZ) (shingles):

  • in adults aged 50 years and older.
  • in adults aged 18 years and older who are or will be at increased risk of HZ due to immunodeficiency or immunosuppression caused by known disease or therapy.

SHINGRIX is not indicated for prevention of primary varicella infection (chickenpox).

  • SHINGRIX is contraindicated in anyone with a history of a severe allergic reaction (eg, anaphylaxis) to any component of the vaccine or after a previous dose of SHINGRIX
  • Review immunization history for possible vaccine sensitivity and previous vaccination-related adverse reactions. Appropriate medical treatment and supervision must be available to manage possible anaphylactic reactions following administration of SHINGRIX

SHINGRIX is a vaccine indicated for prevention of herpes zoster (HZ) (shingles):

  • in adults aged 50 years and older.
  • in adults aged 18 years and older who are or will be at increased risk of HZ due to immunodeficiency or immunosuppression caused by known disease or therapy.

SHINGRIX is not indicated for prevention of primary varicella infection (chickenpox).

Important Safety Information

  • SHINGRIX is contraindicated in anyone with a history of a severe allergic reaction (eg, anaphylaxis) to any component of the vaccine or after a previous dose of SHINGRIX
  • Review immunization history for possible vaccine sensitivity and previous vaccination-related adverse reactions. Appropriate medical treatment and supervision must be available to manage possible anaphylactic reactions following administration of SHINGRIX

Indication & Important Safety Info

Indication

Important Safety Information

Indication

SHINGRIX is a vaccine indicated for prevention of herpes zoster (HZ) (shingles):

  • in adults aged 50 years and older.
  • in adults aged 18 years and older who are or will be at increased risk of HZ due to immunodeficiency or immunosuppression caused by known disease or therapy.

SHINGRIX is not indicated for prevention of primary varicella infection (chickenpox).

Important Safety Information

  • SHINGRIX is contraindicated in anyone with a history of a severe allergic reaction (eg, anaphylaxis) to any component of the vaccine or after a previous dose of SHINGRIX
  • Review immunization history for possible vaccine sensitivity and previous vaccination-related adverse reactions. Appropriate medical treatment and supervision must be available to manage possible anaphylactic reactions following administration of SHINGRIX
  • In a postmarketing observational study, an increased risk of Guillain-Barré syndrome was observed during the 42 days following vaccination with SHINGRIX
  • Syncope (fainting) can be associated with the administration of injectable vaccines, including SHINGRIX. Procedures should be in place to avoid falling injury and to restore cerebral perfusion following syncope
  • Solicited local adverse reactions reported in individuals aged 50 years and older were pain (78%), redness (38%), and swelling (26%)
  • Solicited general adverse reactions reported in individuals aged 50 years and older were myalgia (45%), fatigue (45%), headache (38%), shivering (27%), fever (21%), and gastrointestinal symptoms (17%)  
  • Solicited local adverse reactions reported in autologous hematopoietic stem cell transplant recipients (aged 18 to 49 and ≥50 years of age) were pain (88% and 83%), redness (30% and 35%), and swelling (21% and 18%)  
  • Solicited general adverse reactions reported in autologous hematopoietic stem cell transplant recipients (aged 18 to 49 and ≥50 years of age) were fatigue (64% and 54%), myalgia (58% and 52%), headache (44% and 30%), gastrointestinal symptoms (21% and 28%), shivering (31% and 25%), and fever (28% and 18%)
  • The data are insufficient to establish if there is vaccine-associated risk with SHINGRIX in pregnant women
  • It is not known whether SHINGRIX is excreted in human milk. Data are not available to assess the effects of SHINGRIX on the breastfed infant or on milk production/excretion
  • Vaccination with SHINGRIX may not result in protection of all vaccine recipients

Please see full Prescribing Information.

To report SUSPECTED ADVERSE REACTIONS, contact GSK at gsk.public.reportum.com or
1-888-825-5249, or VAERS at 1-800-822-7967 or www.vaers.hhs.gov.

References

  1. Data on file, GSK.
  2. Kirchhoff SM. Selected Health Provisions of the Inflation Reduction Act. Congressional Research Service. 2022; 1-3. Accessed March 1, 2024. https://crsreports.congress.gov/product/pdf/IF/IF12203
  3. Immunization Information Systems: CPT codes mapped to CVX codes. Centers for Disease Control and Prevention. Reviewed August 9, 2024. Accessed August 28, 2024. https://www2.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=cpt
  4. CPT® category: new immunization* vaccines codes (including incorporation of ACIP abbreviations listing) long descriptors (*for the purposes of CPT coding, “Immunization” includes vaccines/toxoids, immune globulins, serum or recombinant products). American Medical Association. Updated July 19, 2024. Accessed August 28, 2024. https://www.ama-assn.org/system/files/vaccine-long-descriptors.pdf
  5. ICD-10-CM official guidelines for coding and reporting. Centers for Medicare & Medicaid Services and the National Center for Health Statistics. April 1, 2023. Accessed August 28, 2024. https://www.cms.gov/files/document/fy-2023-icd-10-cm-coding-guidelines-updated-01/11/2023.pdf
  6. Immunization Information Systems: IIS: HL7 standard code set MVX – manufacturers of vaccines. Centers for Disease Control and Prevention. Reviewed August 9, 2024. Accessed August 28, 2024. https://www2.cdc.gov/vaccines/iis/iisstandards/vaccines.asp?rpt=mvx
  7. Immunization Information Systems: Current HL7 standard code set CVX -- vaccines administered. Centers for Disease Control and Prevention. Reviewed August 9, 2024. Accessed August 28, 2024.  https://www2a.cdc.gov/vaccines/IIS/IISStandards/vaccines.asp?rpt=cvx

Questions About SHINGRIX?

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