updated 9/25/2006 8:52:25 PM ET 2006-09-26T00:52:25

Cornelia Jefferson vividly recalls the excruciating pain that shingles caused her mother and brother. So when her doctor got a supply of the new shingles vaccine, the retiree jumped at the chance — without knowing if her insurance would pay or she would be stuck with a bill for more than $150.

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The shingles vaccine called Zostavax was hailed as a way to prevent an agonizing rite of aging when it hit the market last spring. But with the pricey shots so far going mostly to those who can afford to pay out of pocket, public health specialists fear the vaccine will be vastly underused, and set back broader efforts to increase immunizations for adults.

“We have built a Jaguar, and we’re going to leave it in the garage,” laments Dr. William Schaffner, a vaccine expert at Vanderbilt University who advises the government on immunization issues.

Topping the concerns: For patients over 65, Medicare will begin paying for the shingles vaccine in January — but not the way it pays for the most widely used adult inoculations, flu shots, which are fully covered. Instead, the shingles vaccine will be treated like a prescription drug, with varying co-pays depending on a patient’s drug plan.

To the dismay of doctors, that also means Medicare won’t reimburse them for actually administering Zostavax, an extra $15 or so they’ll have to pass up or charge directly to patients.

Pharmacists might be best route
Laws in all but six states explicitly allow pharmacists to immunize adults, and drugstores have become a leading flu-shot provider. So this fall, pharmacists are being urged to add shingles shots to the menu; they’ll get the Medicare reimbursement directly. For many Medicare recipients, a trip to the drugstore might be the simplest way to get Zostavax, says Medicare’s Dr. Jeffrey Kelman.

But the shingles vaccine isn’t just for those old enough for Medicare. It was approved for sale to people 60 and over. Next month, when the government’s vaccine advisers issue the first official guidelines on Zostavax’s use, doctors will debate whether those even younger also should be immunized if they’re at high risk of shingles.

Most insurers for the under-65 set are awaiting those guidelines before deciding how or whether to cover the shots, according to the trade group America’s Health Insurance Plans. The biggest question: Whether the guidelines will say every senior eligible for Zostavax should get it, or just consider getting it.

More than ever before, vaccines aren’t just for kids. In addition to Zostavax, whooping cough booster shots were recently recommended for adults up to age 64, and a cervical cancer vaccine hit the market aimed at adolescents and those in their 20s.

These new-generation adult vaccines cost well more than $10 or $20 for old standbys that protect against the flu or tetanus. Nor is there a national program to guarantee access to immunizations for adults who can’t afford them — like there is for children.

The cervical cancer vaccine is the priciest, at more than $300 for a three-shot series, but only a small number of adults qualify for it. Millions are candidates for Zostavax — making the one-dose shingles shot, priced around $150, the big test case to see if doctors can get more adults interested in immunizations.

Millions at risk for shingles
Why? Anyone who ever had chickenpox is at risk for shingles. The chickenpox virus lies dormant inside the body for decades and then erupts, causing itching, burning and tingling with a red rash that develops into pus-filled blisters. It strikes about 1 million Americans a year, mostly those 60 and older. Up to 200,000 of them have a particularly bad type of nerve pain that can persist for months or years, the kind of pain Jefferson, 62, watched afflict her mother and brother.

“She couldn’t stand for clothes to even touch her,” recalls Jefferson, of Franklin, Tenn. Her brother had a tooth pulled before discovering his yearlong pain was actually shingles penetrating nerves in his head. “If this vaccine will prevent that, it’ll be great.”

Zostavax doesn’t treat active shingles, but boosts a patient’s immunity to prevent the chickenpox virus from re-emerging. Studies by manufacturer Merck & Co. Inc. found the shot cut cases of shingles in half, and that shingles cases that still occurred were far less painful. But the vaccine is made with a live virus, so it’s not for people with HIV or other conditions that weaken the immune system.

Merck won’t say how many shots it has sold to date. Led by the American Medical Association, doctors groups have begun protesting that Medicare’s just-finalized payment plans will limit the number who ultimately offer Zostavax.

It’s the law, responds Kelman: Congress set up a provision that allows Medicare recipients free vaccination against flu, pneumonia and in some cases hepatitis, with their doctors paid $15 for each jab to cover time and expenses. But the law makes clear that other vaccines used to prevent disease must be treated as prescription drugs, with no doctor fee, he says.

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