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Zostavax (GEN)
Posted February 6, 2008
Zostavax is a herpes zoster vaccine. It reduces the risk of getting herpes zoster "shingles" in individuals 60 years of age and older. In people who were 70 years of age and older, and still developed shingles even though they had been vaccinated, Zostavax reduced the frequency of post herpetic neuralgia (PHN). Zostavax will not work to treat PHN. The benefit of Zostavax in preventing PHN is due to the effect of the vaccine on reducing the risk of developing herpes zoster (shingles).
We have had some inquiries in relation to coverage of Zostavax and have received some claims for Zostavax. This Part B Medicare contractor cannot pay for a preventive vaccine which has not had a legislative exemption. To do so would be contrary to the Social Security Act, Title 18, §1862(7).
However, from January 1, 2007, through December 31, 2007, we can pay for the administration of Part D covered vaccines through HCPCS code G0377, as provided in Change Request 5459 (as a result of the Tax Relief and Health Care Act of 2006); priced comparable to CPT code 90471, which equals $18.13. We cannot pay for the vaccine itself. Coverage and payment for the Zostavax vaccine itself would be a Part D issue. As of January 1, 2008, coverage for the administration will be included in the Part D reimbursement for the vaccine.
Further information on this matter may be obtained in MLN Matters special edition article SE0727, which is available at www.cms.hhs.gov/MLNMattersArticles/downloads/SE0727.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site. This will provide the varied scenarios for 2008 regarding Part D vaccines, with some information in relation to Part B. |
