Changes to Shingles Vaccine, Insulin Coverage; Insulin Special Enrollment Period

Nov. 23, 2022

Changes to Shingles Vaccine, Insulin Coverage; Insulin Special Enrollment Period

The Inflation Reduction Act includes important changes to member Part D cost-sharing beginning Jan. 1, 2023:

Adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) ,
including the shingles vaccine, will be covered with $0 cost-sharing.
Insulin users will pay no more than $35 for a month’s supply and will not be subject to the deductible.

No Cost-Share for Shingles Vaccine
Shingles (herpes zoster) is the same virus that causes chicken pox in children. The virus stays dormant in the body and can reactivate years later, causing shingles. About one in 3 million people in the U.S. will develop shingles in their lifetimes.

The Centers for Disease Control and Protection (CDC) recommends that adults 50 years and older get two doses of the shingles vaccine to prevent the disease and possible complications. Shingles vaccines are more than 90% effective. The vaccine can be administered by either a doctor or pharmacist and should be taken even if an individual has experienced shingles in the past.

There is no maximum age for this vaccine. Members are encouraged to use our Provider Finder^® to find a physician or an in-network pharmacy that can provide this vaccine.

Changes for Insulin Users
The Centers for Medicare & Medicaid Services also announced that insulin users with Medicare will have access to insulin for no more than $35 for a month’s supply. They won’t pay a deductible for their covered insulin products. The new rules begin Jan. 1, 2023, for insulin covered under Medicare prescription drug plans and July 1, 2023, for insulin used through a traditional pump covered under traditional Medicare’s durable medical equipment benefit. This change sets a cap on insulin cost-sharing that will help at least 1.4 million people with Medicare.

Important Notice on Reimbursements
Prime Therapeutics^® or the health plan will make sure that Medicare members don’t pay more than $35 per month for insulin or any out-of-pocket costs for adult vaccines. However, until Jan. 23, 2023, it is possible that Medicare members might be charged more than $35 per month for insulin or $0 for adult vaccines.

If that is the case, Prime Therapeutics or the health plan will automatically generate a payment to members for any amount paid over $35 for insulin or $0 for vaccines and will mail members a check. Member will not have to do anything to obtain the reimbursement if they were charged more than $35 per month for covered insulin, or more than $0 for an adult vaccine. We expect any reimbursement checks to be mailed by Jan. 31, 2023.

Special Enrollment Period (SEP) for Insulin Users
In addition, the Centers for Medicare & Medicaid Services is granting an SEP for insulin-dependent beneficiaries to add, drop or change their Part D coverage if they find a better option after the 2023 AEP ends on Dec. 7, 2022.

This SEP will run from Dec. 8, 2022, through Dec. 31, 2023.
Beneficiaries must call 1-800-MEDICARE to enact any requested changes.
Beneficiaries’ True Out-of-Pocket costs carry-over from one plan to the next.

Blue Cross and Blue Shield of Illinois (BCBSIL) contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics. MyPrime.com is an online resource offered by Prime Therapeutics.