Medicare And Other Vaccinations
In addition to the shingles vaccine, Medicare Part D plans are required to cover most commercially available vaccinations. According to the Department of Health and Human Services, Medicare Part D plans must cover all vaccines that are commercially available, reasonable and necessary to prevent illness, and not covered by Medicare Part B.
Dont Overpay: Advice For Medicare Patients
Three out of four Americans eligible for the shingles vaccination still havent gotten it, according to the CDC. Not surprisingly, a 2015 report from the National Vaccine Program found that one of the main reasons adults skip recommended vaccines is the cost.
If youve been putting off getting your shingles shot because you were quoted a high price, check your Part D plan. You may be able to get it for less.
Confusion about insurance coverage for the vaccine can sometimes result in patients paying more than they should, Avitzur says.
Dont delay, as the consequences of shingles can be devastating, advises Avitzur, a neurologist who has seen firsthand the painful effects of lingering nerve damage.
Your best bet may be to get the shot at a pharmacy in your drug plans network. Youll still need to get a prescription from your doctor, but the pharmacy will bill your insurance company and youll pay the lowest out-of-pocket costs available under your plan.
If you would like to get vaccinated at your doctors office, ask up front about the cost. Does your doctor charge more to administer the shot than your plan allows? If so, youll be on the hook for the difference. Also see whether the office will bill your Part D or Medicare Advantage plan directly or work with a pharmacy in your network to handle the billing.
S Of Medicare That Cover The Shingles Vaccine
The part of Medicare that covers the vaccine is your Medicare Part D plan or the Medicare prescription drug plan. Remember that a Part D plan is optional, so you might not be enrolled in one of these plans unless you decide to sign up for coverage. Part D typically provides coverage for prescription drugs, and the shingles vaccine is one drug that most plans cover. If you are enrolled in a Medicare Advantage plan, then your plan likely includes prescription drug coverage that will cover the vaccine. Since these Advantage plans are insurance plans administered by private insurance companies, you should contact your provider if you have any specific coverage questions or need help with the details of your plan. Many people also wonder if Medicare covers eye exams. These Medicare Advantage plans often include additional benefits like dental and vision coverage.
Original Medicare will not cover the shingles vaccine. Medicare Part A, or hospital insurance, pays for hospital stays and inpatient care. Vaccines and preventive services are never covered under Medicare Part A. Medicare Part B, which is more traditional medical insurance, pays for doctors office visits, outpatient care, and many preventive services. Part B will cover many immunizations, like the flu vaccine, pneumonia vaccine, and hepatitis B vaccine. Unfortunately, Part B does not cover the shingles vaccine. If you are not enrolled in a Part D plan, then this vaccine will be an out-of-pocket cost for you.
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Pain And Complications Of Shingles In Elderly People
Older adults who develop shingles are often surprised at how painful it is. Many say that it is far more painful than the original chickenpox virus that affected them in childhood. Often the skin in the area of the rash continues to hurt even after the rash has healed.
The individual may feel stabbing or throbbing or even weakness. Doctors call this post-herpetic neuralgia, and it can sometimes last for months or even years.
There are also risks for older adults who develop shingles. The blistered area of skin can become infected, requiring antibiotics in addition to antivirals. Such infections can lead to scarring. The rash is also uncomfortable and makes it challenging to rest. When healing takes longer than usual, some individuals can feel despair or even depression. In rare cases, it can lead to encephalitis.
The virus can also be transmitted to other parts of your body, such as your eyes or lips. The herpes virus can cause outbreaks that may affect hearing and vision.
Another thing to be concerned about is contagion. While shingles itself is not contagious, the virus that causes it is. If your spouse has never had chickenpox and has not been vaccinated, he or she could develop chickenpox as an adult. Its important to keep your skin clean and dry and prevent it from rubbing against any other person who could get infected.
Where To Get The Shingles Vaccine
You have a few different options on where to get the shingles vaccine. You usually can receive it directly from your doctor at a doctors office or at a pharmacy.
The major pharmacy chains typically offer shingles shots so you should be able to get it at a location near you. You will still need a prescription from your doctor in order to get it at a pharmacy.
Who Can Administer Your Shingles Shot?
The vaccine is administered as a shot to your upper arm. While the Shingrix vaccine is safe and effective at preventing shingles, there are some possible side effects. According to the CDC, you may experience some common mild symptoms associated with vaccines, such as arm soreness, muscle pain or a headache.
Remember that the vaccine comes in two doses, so you will have to return to wherever you got the shot two to six months later to receive the second dose. The immune reaction may come with the first or second dose, or with both doses of Shingrix.
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How Well Does Zostavax Work
Zostavax®, the shingles vaccine, reduced the risk of shingles by 51% and the risk of post-herpetic neuralgia by 67% based on a large study of more than 38,000 adults aged 60 years or older. Protection from shingles vaccine lasts about 5 years.
While the vaccine was most effective in people 60 through 69 years old, it also provides some protection for people 70 years old and older.
Adults vaccinated before age 60 years might not be protected later in life when the risk for shingles and its complications are greatest.
Some Vaccines Covered Better Than Others
Unlike the flu and pneumonia vaccines, which are fully covered as preventive services under Medicare Part B, the shingles shot and other recommended vaccinations are covered as prescription drugs under Medicare Part D and Medicare Advantage plans.
Some of those plans provide better coverage than others, but nearly all of them divide their formularies, or list of covered drugs, into tiers according to cost. Drugs in Tier 1 and 2, mainly lower-priced generics and preferred brand-name drugs, have lower co-pays than more expensive nonpreferred brands in Tier 3 or 4.
Consumer Reports found that many Part D plans categorize the shingles vaccine, Zostavax, as an expensive Tier 3 or 4 drug. Only one pharmaceutical companyMerckmakes the shingles shot, and theres currently no generic version.
That means if you havent met your annual deductible, youll likely wind up paying full price for the shot, which is about $217. But depending on your plan, even after the deductible is met, consumers may have to pay a significant part of the shingles vaccine costup to $100.
Many healthcare providers havent set up billing systems to file claims through prescription drug plans. So if youre vaccinated at your doctors office, you might be required to pay the full shingles vaccine cost up front and then file to be reimbursed by your insurance.
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Why Is The Shingles Vaccine Not Covered By Medicare
Medicare Part B covers COVID-19, influenza and pneumococcal vaccines. It may also cover the Hepatitis B vaccine if your doctor thinks you are at a higher risk of contracting the disease. However, original Medicare doesnt cover the shingles vaccine, and its unclear exactly why.
However, you may be covered for the shingles vaccine if you purchase Medicare Part D insurance through an approved private insurer or have a Medicare Advantage Plan that includes Part D coverage. However, youll be liable for your Part D deductible if you havent already paid it in the year you have your shingles vaccine. Part D deductibles vary widely between providers, but there is a mandatory maximum cap of $445 as of 2021.
The only commercially available shingles vaccines are Shingrix and Zostavax. The average cost of a Shingrix shot is around $190, so beneficiaries who havent yet paid their deductible are likely to end up paying for the entire cost of their shingles vaccine.
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How Does Medicare Cover The Shingles Vaccine
Original Medicare, Part A and Part B, does not cover the shingles vaccination but Medicare Part D does. To get this covered, you must enroll in either a stand-alone Medicare prescription drug plan or a Medicare Advantage plan that includes prescription drug coverage . You may have a copayment for the shingles vaccine.
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Is Vaccine Coverage Worse In The 12 States That Havent Expanded Their Medicaid Programs Than In Those That Have
Although it may seem that there could be less adult vaccine coverage in states that havent expanded Medicaid, that isnt the case. In fact, all of these states offer some vaccine coverage. Compared to the states that have expanded Medicaid, they dont fall behind due to the variation that still exists in those states.
For context, here are the 12 states that havent expanded Medicaid:
To give you a better idea of the variation among these non-expanded states, here are a few examples of the vaccine coverage they offer for adults:
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Alabama Medicaid covers five of the recommended adult vaccines .
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Mississippi Medicaid covers all 13 recommended vaccines.
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Wyoming Medicaid provides flu shots for all adult members, but other vaccine coverage will depend on the plan you have.
Find Medicare Advantage Coverage For The Shingles Vaccine
Contact a licensed insurance agent today to find out if a Medicare Advantage plan is available where you live that will cover the shingles vaccine.
Find Medicare plans that cover the shingles vaccine
Or call 1-800-557-6059TTY Users: 711 to speak with a licensed insurance agent. We accept calls 24/7!
1 Umansky, Diane. The New Shingles Vaccine: What You Should Know About Shingrix. . Consumer Reports. Retrieved from www.consumerreports.org/shingles-vaccine/new-shingles-vaccine-shingrix-what-you-should-know.
2 Centers for Disease Control and Prevention. Shingles Vaccination. . Retrieved from www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html.
About the author
Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles hes written, helping Americans better understand their health insurance and Medicare coverage.
Christians work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.
Christians passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.
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How Much Does The Shingles Shot Cost
There is currently only one shingles vaccine available in the United States, sold under the brand name Shingrix. An older shingles vaccine called Zostavax was taken off the market in November 2020.
Shingrix is delivered in two shots. Without insurance, each shot retails for around $202 for a total of $404, according to GoodRX in 2021. Discounts can lower that cost by nearly $50 per shot.
Medicare Part D and Medicare Advantage plans may cover most of the cost of the Shingrix vaccine, but you could have out-of-pocket costs for both the shot and your doctor visits.
Before getting the vaccine, check with your plans administrator to make sure your policy covers the shingles shot.
What Are The Possible Side Effects Of Shingrix
Studies show that Shingrix is safe. The vaccine helps your body create a strong defense against shingles. As a result, you are likely to have temporary side effects from getting the shots. The side effects might affect your ability to do normal daily activities for 2 to 3 days.
Most people got a sore arm with mild or moderate pain after getting Shingrix, and some also had redness and swelling where they got the shot. Some people felt tired, had muscle pain, a headache, shivering, fever, stomach pain, or nausea. Some people who got Shingrix experienced side effects that prevented them from doing regular activities. Symptoms went away on their own in about 2 to 3 days. Side effects were more common in younger people.
You might have a reaction to the first or second dose of Shingrix, or both doses. If you experience side effects, you may choose to take over-the-counter pain medicine such as ibuprofen or acetaminophen.
Guillain-Barré syndrome , a serious nervous system disorder, has been reported very rarely after Shingrix. There is also a very small increased risk of GBS after having shingles.
If you experience side effects from Shingrix, you should report them to the Vaccine Adverse Event Reporting System . Your doctor might file this report, or you can do it yourself through the VAERS websiteexternal icon, or by calling 1-800-822-7967.
If you have any questions about side effects from Shingrix, talk with your doctor.
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Shingrix: Doses And Vaccine Information
Shingrix is an injection, with two doses spaced two to six months apart. Shingrix is the CDC recommended vaccine for shingles prevention. This vaccine contains inactivated viruses, which makes it more tolerable for people with compromised immune systems. Receiving two doses of Shingrix provides strong protection against shingles.
How Do I Know If My Medicare Plan Covers Shingrix
To check details of your coverage, call the customer service number for your Medicare Advantage or Medicare Part D plan. This number is typically located on the back of your Medicare Advantage plans ID card. If youre a Network Health Medicare Advantage member, you can call member experience at 800-378-5234 , MondayFriday from 8 a.m. to 8 p.m. From October 1 March 31, we are available seven days a week from 8 a.m. to 8 p.m.
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Does Medicare Cover The Shingles Vaccine Will I Have To Pay For The Shot
The CDC recommends people 50 years and older get the shingles vaccine. The shot is widely available and the cost may be covered if you have Medicare Advantage or Medicare Part D. Depending on your plan, you may have to cover a deductible, co-pay, or pay for the shot out of pocket and get reimbursement.
Shingles can cause serious complications, like painful long-term nerve damage. To stay safe from such complications, you may want to consider the new shingles vaccine . An older vaccine once widely administered in the U.S. was less effective and is no longer on the market.
What Is Shingles And How Is It Related To Chickenpox
Shingles is a reactivation of the varicella-zoster virus in the body. This virus is responsible for chickenpox. As you age, the risk of developing this painful rash-like condition increases, leading many people to seek preventive immunization from its potentially severe effects.
As far as symptoms go, shingles causes a painful rash that may appear as a strip of blisters on the trunk of the body. The blisters continue to form over three to five days, eventually drying and forming a scab-like layer.
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How Much Does Shingrix Cost
The amount you pay will depend on your plan coverage and where you get the vaccine. For the best cost options, youll likely want to choose a pharmacy in your network.
Youll still need a doctors prescription for the vaccination. Youll find most major chains and some independent pharmacies can administer the vaccine.
If youre a Network Health Medicare Advantage member, check your Evidence of Coverage for details..
If youre vaccinated in a doctors office you will likely owe an office visit copayment.
Does Medicare Cover The Shingles Vaccine In 2022
The best way to prevent shingles is through a shingles vaccination however, Original Medicare will not cover this service. Luckily, Medicare Part D plans usually do.
FYI: If you plan to apply for Medicare, be sure to read our rundown of documents needed for Medicare.
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Who Should Not Get Shingrix
You should not get Shingrix if you:
- Have ever had a severe allergic reaction to any component of the vaccine or after a dose of Shingrix.
- Currently have shingles.
- Currently are pregnant. Women who are pregnant should wait to get Shingrix.
If you have a minor illness, such as a cold, you may get Shingrix. But if you have a moderate or severe illness, with or without fever, you should usually wait until you recover before getting the vaccine.
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Vaccines Covered By Medicare Part B
Medicare Part B covers three important vaccines as part of its preventive care benefits.
Covered vaccines include the following:
- Flu vaccine: Annual vaccine given in one shot before or during flu season, usually November through April
- Pneumonia vaccine: One-time vaccine given in two shots at least one year apart
- Hepatitis B vaccine: One-time vaccine given in two to four shots over one to six months for people who are medium to high risk, including people with diabetes
Part B also covers vaccines you may need if youre exposed to a harmful virus or bacteria by accident. You might need a tetanus shot, for example, if you step on a rusty nail. Or you may need rabies shots if youre bitten by a stray dog.
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