Coverage & Coding

SHINGRIX has broad insurance coverage for your patients. For billing, use the codes listed below the coverage section.

Coverage

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Nationally, payers covering 96% of commercial medical benefit enrollees cover SHINGRIX1,*

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Nationally, payers covering 100% of Medicare Part D enrollees cover SHINGRIX1,*

Commercial medical benefit enrollees

  • Primarily people <65 years
  • 90% of privately insured patients pay no or limited out-of-pocket costs with the average cost being less than $5 per dose2

The Affordable Care Act (ACA) requires all Health Insurance Marketplace plans and most other private health insurance plans to cover all Advisory Committee on Immunization Practices recommended vaccines, including SHINGRIX, with no cost sharing (deductibles, copayments or coinsurance) if administered in-network.3

 

Medicare Part D enrollees

  • Primarily people ≥65 years
  • Majority of patients pay an out-of-pocket cost of less than $50 per dose2
  • More than 95% of Medicare Part D enrollees receive SHINGRIX at a pharmacy2

Medicare requires that Part D plans cover SHINGRIX and other available vaccines, but does not mandate specific out-of-pocket costs.4

Part D enrollee costs will vary according to the plan’s benefit design, formulary tier placement of SHINGRIX, and the enrollee’s own use of Part D drugs.4

Per Medicare policy, shingles vaccines are only covered in Part D plans, not in Part B. Part D covered vaccinations are typically administered at a retail site of care (pharmacy).4

 

WHAT YOU NEED TO KNOW

Coverage, coding, cost to patient, reimbursement amount for product and administration fee will vary by payer, plan, patient, professional setting or services rendered, and are subject to change without notice. Cost to patients may vary. Coverage and reimbursement decisions are made by individual payers following receipt of claims from providers. Providers must follow payer documentation and billing requirements.

*SOURCE: Managed Markets Insight & Technology, LLC, Database as of January 2021. “Coverage” is formulary access without restrictions, which means reimbursement from a health plan with no accompanying step edits or prior authorizations. Veteran’s Affairs (VA) and Indian Health Service (IHS) lives have been omitted when calculating the percentage of lives for this geography.

Coding

 

Use the following codes when billing SHINGRIX:

 

CPT Code (Product):

90750

 

CPT Code (Administration)
 

1 vaccine administered:
 

Each additional vaccine administered during same encounter:

   
 

90471
 

90472

 

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

Z23

 

Administration Modifier for Medicare:

GY

 

MVX Code:

SKB

 

CVX Code:

187

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).

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

How SHINGRIX is supplied

SHINGRIX Outer Package of 1 Dose

SHINGRIX is supplied as an outer package of 1 dose (NDC 58160-819-12) containing:

  • Adjuvant Suspension Component (Vial 1 of 2) NDC 58160-829-01
  • Lyophilized gE Antigen Component (Vial 2 of 2) NDC 58160-828-01
SHINGRIX Outer Package of 10 Doses

SHINGRIX is supplied as an outer package of 10 doses (NDC 58160-823-11) containing:

  • Adjuvant Suspension Component (10 vials) NDC 58160-829-03
  • Lyophilized gE Antigen Component (10 vials) NDC 58160-828-03

gE=glycoprotein E.

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

You may also be interested in:

See how you and your staff can reconstitute SHINGRIX in 4 steps. Vaccinate confidently.

Learn how to store SHINGRIX and about the importance of proper dosing.

Talk to your patients about what to expect, including common adverse reactions.