Does Medical Cover Shingles Vaccine

Who Should Not Get The Shingrix Vaccine

Most healthy people aged 50 and older should get the Shingrix vaccine, even if they meet the criteria listed above. However, there are some groups of people who should not receive the Shingrix vaccine. These include:

• People who have had a severe allergic reaction to any ingredient of the Shingrix vaccine or the vaccine itself.

• People who have tested negative for immunity to the virus that causes shingles, the varicella zoster virus. People who test negative should receive the chickenpox vaccine instead.

• People who currently have shingles.

• People who are currently pregnant or breastfeeding.

• People who have a moderate or severe acute illness, including those with a fever of 101.3 degrees Fahrenheit or higher. These people should wait to receive the vaccine until they recover.

Does Medicare Cover Shingrix Or Zostavax

Many Medicare Part D and Medicare Advantage plans provide coverage for Shingrix and/or Zostavax.

• Medicare Part D plans provide coverage exclusively for prescription drugs.
• Medicare Advantage plans provide coverage for all Medicare Part A and Part B benefits, and most Medicare Advantage plans also cover prescription drugs. Some plans also offer dental, vision and hearing benefits, along with a range of other benefits that Original Medicare doesn’t cover.

Both Medicare Advantage plans and Part D plans are sold by private insurance companies.

Does Medicare Cover The Shingles Vaccine

Currently, the shingles shot is covered by and Medicare Advantage plans with Medicare Part D prescription drug coverage, but not under Original Medicare .

Starting January 2023, people with Medicare Part D prescription drug coverage wont pay any out-of-pocket costs for the shingles vaccine.*

Heres some helpful information on the symptoms and causes of shingles, Medicare coverage of the vaccine and where to get a shot.

Also Check: What Are The Very First Signs Of Shingles

What Side Effects Are Associated With The Shingrix Vaccine

There are some side effects associated with the Shingrix vaccine that your healthcare provider will speak to you about, but for the most part, they are mild and last two to three days. The most common side effect is soreness in the arm that receives the vaccine. Other side effects include:

More To Explore

What Are The Benefits Of Shingles Vaccines

The shingles vaccine can help reduce the risk of developing shingles and can also reduce the severity of symptoms if you do develop the condition. Additionally, it can protect people who have already had shingles from getting the condition again. In some cases, the vaccine can even help reduce the risk of complications from shingles, such as postherpetic neuralgia.

Also Check: Will Shingles Go Away On Its Own

Who Is Eligible For Medicare

Eligibility for Medicare and Medicaid is a key difference between the two programs. Medicare is available to any individual over the age of 65, as well as to certain individuals with disabilities. This includes individuals who have been receiving Social Security disability benefits for at least two years, individuals with end-stage renal disease, and those with Amyotrophic Lateral Sclerosis .

Where To Get Vaccinated

You have a choice on where to get vaccinated.

In your doctors office: You can get vaccinated in your doctors office. If the office is set up to bill Part D directly for your vaccination, you may only have to pay a copay at the time of your shingles shot. If not, you may have to pay all costs upfront and submit a claim to your Part D plan for reimbursement.

At your local pharmacy: You can go to your local pharmacy to get your shingles shot as long as they offer the vaccine and appropriately trained staff members administer it. The rules for pharmacy vaccination vary by state. You will likely need to pay for the vaccination upfront. Pharmacies are not legally required to dispense medications without payment.

Read Also: Reactions To Second Shingles Shot

Does Medicare Cover The Shingles Shot

Summary:

There are two types of shingles vaccines, Zostavax and Shingrix, that may help prevent shingles. Neither Original Medicare nor Medicare Advantage cover the shingles vaccine on their own, but you can generally get Medicare coverage for a shingles vaccine through Medicare Part D, which is optional prescription drug coverage through a private health insurance company.

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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What Are The Two Types Of Shingles Vaccines

The two options for the shingles shot are Zostavax and Shingrix. Zostavax, according to the Mayo Clinic, protects against shingles for about five years. Itâs a live vaccine given as a single shot in the upper arm. The Zostavax shingles shot is recommended to adults age 60 and over which reduces the risk of developing shingles by 51%, according to the Centers for Disease Control and Prevention .

Studies suggest that Shingrix offers protection against shingles for more than five years. Itâs a nonliving vaccine given in two doses.

What Is The Shingrix Vaccine Used To Prevent

The Shingrix vaccine cannot be found over-the-counter and is used to prevent the onset of shingles and postherpetic neuralgia, a complication of shingles, in older adults. Explanations of these conditions are provided below.

Shingles

Shingles is a disease caused by the same virus that causes chickenpox, called varicella zoster virus, also known as herpes zoster. People who experience chickenpox as children, which is estimated to be 99 percent of American adults, have the virus lying dormant in their bodies after they recover from chickenpox. The virus does not ever fully go away, so when peoples immune systems weaken as they age, the virus can come back and cause shingles. Shingles is an uncomfortable disease characterized by a painful rash that usually develops on one side of the face or body. The rash consists of blisters that take about seven to ten days to scab over and between two and four weeks to fully clear. Most people who have shingles experience the rash on either the left or right side of the body in a single stripe, but sometimes, it occurs on one side of the face. People who have the shingles rash on their face can sometimes experience vision loss. In addition to the characteristic rash, other symptoms of shingles include:

Postherpetic neuralgia

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Who Should Get The Shingrix Vaccine

The Centers for Disease Prevention and Control recommends that healthy adults aged 50 and older receive the Shingrix vaccine in order to protect themselves against shingles. The vaccine should be administered in two doses, separated by two to six months, in order to protect against contracting the shingles virus and experiencing complications from the virus, including postherpetic neuralgia. Other shingles vaccines, such as Zostavax, do exist and have been in use since 2006. However, the Shingrix vaccine is preferred and is recommended over Zostavax. Patients who are allergic to Shingrix, need immediate vaccination and do not have access to Shingrix, or prefer the Zostavax vaccine over Shingrix may still use the Zostavax vaccine if they are healthy and aged 60 or older. However, even patients who have already received Zostavax are recommended to receive the Shingrix vaccine, as it is more effective at preventing shingles. People should get the Shingrix vaccine even if the following are true:

• They have had shingles in the past.

• They have received the Zostavax vaccine.

• They are not sure if they have had chickenpox.

Medicare Coverage For Shingles Vaccine

Shingrix is not the first shingles vaccine, but it is the only one currently on the market in the United States.Instead of using a live virus,the vaccine uses a protein from the virus to trigger an immune response. It is administered in two doses two to six months apart.

This shingles vaccine has been shown to decrease the risk for shingles by 97% for people between 50 and 69 years old and by 91% for people 70 and older. It reduces complications as well. The risk for post-herpetic neuralgia goes down by 91% and 89%, respectively, in those age groups.

Because the vaccine works well, it is important to know if and when Medicare covers it.

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How Can I Get A Shingles Vaccine

While most people get their shingles shots at a pharmacy, some receive it at their doctors office. At one time, some states required a prescription to get the shingles vaccine at a pharmacy, but those states have recently changed their rules. Now you dont need a prescription to get the shingles vaccine.

At a pharmacy. Pharmacists in all states can administer vaccines included on the CDC-recommended adult immunization schedule, including the shingles vaccine. Make sure your pharmacy is in your Part D plans network so it can bill your plan directly. Check with your pharmacy and insurance plan for details.

At a doctors office. Its a good idea to confirm your doctor can bill Medicare Part D before you plan to get the vaccine there. Otherwise, you may need to pay for the vaccine and submit a claim for reimbursement to your Part D plan. Ask the doctors office and your plan about the rules.

Keep in mind

If you have trouble affording Part D prescription drug coverage, you may qualify for the Extra Help program, a government program that helps people with limited income and assets pay premiums and out-of-pocket costs for Part D drug coverage. Starting in 2024, the Inflation Reduction Act also expands the level of income eligibility for the Extra Help program.

Update October 11, 2022

How Well Does Shingrix Work

Two doses of Shingrix provide strong protection against shingles and postherpetic neuralgia , the most common complication of shingles.

• In adults 50 to 69 years old with healthy immune systems, Shingrix was 97% effective in preventing shingles in adults 70 years and older, Shingrix was 91% effective.
• In adults 50 years and older, Shingrix was 91% effective in preventing PHN in adults 70 years and older, Shingrix was 89% effective.
• In adults with weakened immune systems, Shingrix was between 68% and 91% effective in preventing shingles, depending on their underlying immunocompromising condition.

In people 70 years and older who had healthy immune systems, Shingrix immunity remained high throughout 7 years following vaccination.

Also Check: At What Age Do You Get Shingles Vaccine

What Everyone Should Know About The Shingles Vaccine

Shingles vaccination is the only way to protect against shingles and postherpetic neuralgia , the most common complication from shingles.

CDC recommends that adults 50 years and older get two doses of the shingles vaccine called Shingrix to prevent shingles and the complications from the disease. Adults 19 years and older who have weakened immune systems because of disease or therapy should also get two doses of Shingrix, as they have a higher risk of getting shingles and related complications.

Your doctor or pharmacist can give you Shingrix as a shot in your upper arm.

Shingrix provides strong protection against shingles and PHN. In adults 50 years and older who have healthy immune systems, Shingrix is more than 90% effective at preventing shingles and PHN. Immunity stays strong for at least the first 7 years after vaccination. In adults with weakened immune systems, studies show that Shingrix is 68%-91% effective in preventing shingles, depending on the condition that affects the immune system.

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.

• Medicare Enrollment Guide

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Is There A Downside To The Shingles Vaccine

Though the vaccine is deemed safe by the U.S. Food and Drug Administration , there are certain conditions in which the vaccine may not be safe for you.

• The shingles vaccine has only been tested in adults over age 50 years and immunocompromised adults above 18 years thus, there is no recommendation for the vaccine for younger ages by the FDA.
• You should not get the vaccine if you have had a severe allergic reaction to a previous Shingrix dose.
• You have tested negative for immunity to varicella-zoster virus .
• You have an active shingles infection.

How Does Medicare Provide Coverage For The Shingles Vaccine

Medicare prescription drug plans and Medicare Advantage plans that provide prescription drug coverage generally cover all commercially available vaccinations. These plans will cover the vaccination medication and the administration of the shot by your doctor or physician. Depending on your plan benefits, you may have to pay a copayment or coinsurance amount. Make sure to follow your planâs guidelines for this vaccination to be covered.

You will pay the least amount of money out of pocket if you are vaccinated at a pharmacy in your drug planâs network. A summary of ways you can pay for your shingles vaccine include:

Medicare

• Medicare Part D plans cover the shingles vaccine. There may be a copay, or you may need to pay the full amount and get reimbursed for some of the cost.
• Original Medicare Part B does not cover the shingles vaccine.

Medicaid

• To learn if your Medicaid coverage pays for the Shingles vaccine, please contact your Medicaid insurer.

Private health insurance

• Private health insurance plans cover the vaccine, but there may be some costs depending on your plan.

Vaccine assistance programs

• Some pharmaceutical companies provide vaccines to those who are eligible and unable to afford costs. C with the vaccine manufacturer, GlaxoSmithKline, about if Shingrix is covered by these programs.

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Does Medicare Cover The Shingles Vaccine In 2022

En español | No and yes. Medicares Part A and Part B dont cover shingles vaccinations, even though the Centers for Disease Control and Prevention recommends that everyone age 50 and older get the vaccine. Medicare Part B covers some other vaccines as free preventive care, such as the flu and pneumonia vaccines.

With that said, Medicare Part D covers the shingles vaccine, as do private Medicare Advantage plans that include drug coverage. These plans must cover all commercially available vaccines needed to prevent illness, except for those that Part B covers.

In the United States, about 1 in every 3 people are at risk for shingles or herpes zoster, the same virus strain that causes chicken pox. If youve had chicken pox, the virus stays dormant in your system and may reappear as shingles later in life, which is why the vaccine is recommended.

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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Other Types Of Plans Do Better

Other forms of insurance do a far better job covering immunizations.

Under provisions of the Affordable Care Act, private planssuch as insurance through your employer or purchased on a state marketplaceare still required to cover recommended vaccinations as preventive medical care, not drugs.

That means that as long as you go to a provider in your plans network, your insurance will pay for preventive care without a co-pay, even if you havent met your deductible.

Its really a shame that older Americans, who are most at risk of contracting shingles and most vulnerable to the potentially serious effects of the disease, often have to pay more than others for the vaccine, says Consumer Reports medical director, Orly Avitzur, M.D.

If youre currently covered by a private health plan but anticipate going on Medicare in the next five years or so, one cost-saving strategy is to talk to your doctor about updating all your vaccinations now while your insurance provides good coverage, Avitzur says. The shingles shot is recommended for nearly all adults aged 60 and older.