Saturday, June 22, 2024

Does Medicare Cover The Shingrix Shingles Vaccine

Go Through A State Pharmaceutical Assistance Program

Everything You Need to Know About Shingrix | CDC experts

Medicare Part D plans have a yearly deductible. After you reach your Medicare Part D plans deductible, you will still be required to pay a copayment or coinsurance for your shingles vaccine. However, if you go through a State Pharmaceutical Assistance Program , you may be able to get help with these costs.

Solving The Part D Oop Problem

When the MMA was passed, vaccine OOP costs were only a theoretical problem. Then, in 2005, the first pertussis-containing vaccine for adults was licensed, followed by the first shingles vaccine in 2006. A 2011 GAO report showed that relatively few Medicare beneficiaries received these vaccines, and cost sharing was cited as a barrier to access.

A 2018 Avalere Health analysis I led found that uptake of the shingles vaccine was 40% to 60% higher when a Part D plan offered $0 cost sharing. In 2016, 95% of Part D beneficiaries encountered vaccine cost sharing, with OOP costs averaging $85. Other studies have affirmed that cost sharing is a definite barrier to vaccine access, resulting in lower uptake.

Over the years, the CMS has encouraged Part D plan sponsors to offer a $0 or low cost-sharing formulary tier for vaccines, but the offering remained optional. Passage of the Inflation Reduction Act now makes this mandatory and removes a barrier to vaccine uptake.

Why Doesn’t Medicare Cover The Shingles Vaccine As Free For All Seniors

Many people think that a vaccine that’s recommended by the CDC for those over age 50 would be fully covered by Original Medicare. However, there are a few reasons why you may end up paying hundreds of dollars for the two-dose regimen.

  • Medicare coverage levels: Some Medicare drug plans have better cost-sharing benefits than others, and how much you pay for the shingles vaccine depends on the plan you choose.
  • Pharmaceutical classification: Medicare classifies the Shingrix vaccine as a part of its pharmaceutical coverage, meaning it would fall under Medicare Part D coverage rather than Part A or Part B. In contrast, most private health insurance, either through an employer or through the marketplace, classifies the shingles vaccine as a part of its free preventative coverage.
  • Type of pharmaceutical: Shingrix is a Tier 3 drug made by GlaxoSmithKline, and there isn’t a generic alternative. This could mean that your out-of-pocket costs are higher than for other medications.

Also Check: How Long Do Shingle Roofs Last In Florida

Does Medicare Part D Cover The Shingles Vaccine

Yes, Medicare Part D is usually able to cover all of the commercially available vaccines, including the shingles vaccine. So, if you are enrolled in Medicare Part D, then you may be covered for it. Its important that you check your Medicare drug plan to learn whether it offers coverage for the shingles shot.

Does Medicaid Cover The Shingles Vaccine

Do Medicare Part D plans cover the shingles vaccine?
  • Does Medicaid cover the shingles vaccine? Find out whether Medicaid covers shingles vaccines like Shingrex, including what you’ll pay and who’s eligible.

Shingles is a painful rash caused by a reactivation of the chickenpox vaccine. The condition can also cause complications such as postherpetic neuralgia, which causes long-term nerve pain. The Centers for Disease Control and Prevention recommends that people over 50 receive two shots of Shingrix, a vaccine that prevents shingles and associated complications. Many people want to know if Medicare covers the shingles vaccine. Below, you can find out everything you need to know about shingles vaccine coverage through Medicaid and Medicare.

Also Check: How To Lessen Shingles Pain

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.

Why Does Medicare Not Cover The Shingles Shot

There are a few reasons why Medicare Part A and Part B do not cover the shingles vaccine. One reason is that the vaccine is not considered to be medically necessary. Medicare only covers preventive care services that are considered medically necessary. Instead, your shingles shot will be covered if you have Medicare Part D, which covers prescription drugs.

Another reason Medicare does not cover the vaccine is that it is not considered to be cost-effective. Medicare only covers preventive care services that are considered to be cost-effective. The shingles vaccine is not currently considered to be cost-effective by Medicare standards in some cases.

Read Also: How Do You Get Shingles In Your Eye

Is The Shingles Shot Covered By Medicare

Original Medicare does not pay for the shingles vaccine. However, if youre enrolled in a Medicare prescription drug plan or have a Medicare Advantage plan that includes drug coverage, your shot may be covered. For vaccines covered under Part D , it is not recommended to get the shot through your providers office, as you may have issues with Part D billing.*

What Steps Can You Take To Make Sure You Are Covered If You Have Medicare Advantage With Drug Coverage Or Medicare Part D

Shingles vaccine is recommended for healthy older adults

If you already have Medicare Advantage, or Medicare Part D, contact your provider to check your coverage. Medicare Advantage plans are offered by private companies that Medicare approves.

If you are not yet on Medicare and want to find a plan that covers the shingles shot, you can use Medicares Find a Medicare Plan tool. This tool allows you to compare Medicare Advantage and Part D plans.

Read Also: How Much Does A Pallet Of Shingles Weigh

Can I Get Shingles If Ive Had Chickenpox Already

Yes. After you have chickenpox, the virus stays in your body. It might go many decades before resurfacing or never come back at all. As you get older, the chance of the virus reappearing as shingles becomes more significant and can also lead to other negative health effects.

It is rare but possible to get shingles more than once.

How To Save Money On Vaccines

If youre uninsured or having trouble paying for your vaccines, talk to your CVS pharmacist.

GoodRx offers discounts on vaccines as well as medications. You can print or show the CVS pharmacist a GoodRx coupon. For the shingles vaccine Shingrix, for example, you can save as much as 22% off the average retail price. Another GoodRx coupon can help save as much as 36% off a Tdap vaccine.

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Can You Get The Shingles Vaccine For Free

The shingles vaccine is manufactured by GlaxoSmithKline Biologicals, a pharmaceutical company. GSK has a patient assistance program that may provide the vaccine to you at no cost if you meet these eligibility criteria:

  • You dont have prescription drug coverage or a Part D plan and have spent at least $600 during the calendar year
  • You are an adult, age 19 or older
  • You live in the U.S., Puerto Rico, or the District of Columbia
  • You dont qualify for Puerto Ricos Government Health Plan
  • Your maximum monthly gross income does not exceed certain limits, depending on where you reside and your household size
  • You apply through your health care provider, who will register for the patient assistance program and submit your application

What Is Shingles And How Do You Catch It

Is Shingrix Covered By Medicare Part F

Shingles is a painful skin rash that forms on one side of the body. It is caused by the same virus that causes chickenpox, the varicella-zoster virus. Shingles can affect people who have had chickenpox, even if they had the illness long ago.

Once youve had chickenpox, the virus becomes inactive in the body and can reactivate years later. The virus can remain inactive in your nerve roots for many years, and then wake up and travel down the path of a sensory nerve to the skincausing shingles. You may develop shingles more than once in your lifetime.

RELATED: Shingles treatments and medications

Read Also: Will The Shingles Vaccine Help With Herpes

About The Shingles Vaccine

The Centers for Disease Control and Prevention recommends that healthy adults over the age of 50 get the shingles vaccine because it’s the only way to protect against the disease and its associated side effects. The risk of getting shingles increases as you age or if you have a weakened immune system. Always consult your doctor to find out if the shingles vaccine is right for you.

The CDC-recommended vaccine, Shingrix, is a recombinant zoster vaccine that has two doses administered within six months of each other. It’s classified as a Tier 3 drug by most insurance companies, which means it’s a brand-name pharmaceutical with a higher copayment than a Tier 1 or 2 drug.

Use the Shingrix vaccine locator to find where the shingles vaccine is being offered, and check with your Medicare Part D or Medicare Advantage provider to see which locations give you the lowest price.

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.

Read Also: Is There A Natural Cure For Shingles

Is Shingrix Covered By Medicaid

Shingrix is a shingles vaccine often given to adults over 50 and younger adults with compromised immune systems. Medicaid likely covers Shingrix in the 38 states with expanded Medicaid coverage and the District of Columbia. You can find out if your state has expanded Medicaid on the Medicaid website. Medicaid is less likely to cover Shingrix in states without expanded coverage.

If Medicaid covers the Shingrix vaccine in your state, you’ll most likely need to have it at an in-network facility. The average copayment for covered beneficiaries is less than $5 per shot.

How Does Medicare Cover The Shingles Vaccine

CDC warns of shingles vaccine shortage

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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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.

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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Is The Shingles Vaccine Covered By Medicare And Can I Get It At Cvs

Because the shingles vaccine requires two doses, if you have to pay full price around $400 total it may approach the $445 maximum Part D deductible that Medicare allows for 2021.

If thats the case, you may want to consider getting your vaccine early in the year. This way you dont have to worry about your deductible resetting in a new plan year soon after meeting it. You should discuss the risks and benefits of this strategy with your healthcare provider.

As far as going to CVS Pharmacy or CVS in Target to get your shingles vaccine, this is definitely an option. You can always call ahead or go online to schedule same-day appointments, or go in on a walk-in basis at many locations.

Brief History Of Medicare Vaccine Coverage

Does Medicare Pay For Shingles Shots?

For much of the 20th century, vaccination efforts concentrated on the childhood population, resulting in the successful reduction of morbidity and mortality associated with at least nine infectious diseases.

Following the development of the first vaccines for older adults, like influenza and pneumococcal disease, Congress amended the Medicare statute throughout the 1980s to ensure beneficiary access to these new vaccines and the Hepatitis B vaccine for those beneficiaries at intermediate to high risk of contracting the disease. As it enacted these coverage requirements under Part B, Congress took care to prohibit beneficiary cost sharing so that seniors would not be discouraged from receiving vaccines.

Eventually, in 2003, Congress passed the Medicare Modernization Act, creating Medicare Part D, a prescription drug benefit for seniors. Under the MMA, implemented in 2005, Part D sponsors must cover all commercially available vaccines except those covered under Part B. This inexplicable decision to cover future vaccines under the prescription drug benefit while leaving previous vaccine coverage in Part B created a peculiar split in Medicare vaccine coverage. There is no meaningful clinical distinction between Part B and Part D vaccines that justifies the separation. The result is an unevenness of vaccine coverage and access across settings of care and population segments, which will be perpetuated as new vaccines for older adults are licensed and recommended.

Read Also: What To Take For Shingles Headache

Medicare Shingles Vaccine Cost

The full cost of the shingles vaccine from Shingrix is $324, spread out across two shingles shots costing $162 each. If you have a prescription drug plan with Medicare, the approximate cost could be less than $50 per shot, a more than 60% discount from the full price!

While the premium of the prescription drug plan may be higher than that of a Medicare Advantage plan, the prescription drug plan will likely save you money on the vaccine in the long run.

Who Needs The Shingles Vaccine

According to the Centers for Disease Control and Prevention , the Advisory Committee on Immunization Practices recommends the shingles vaccine for people aged 50 and older. It is a manufactured inactivated vaccine intended to prevent shingles. The vaccine is administered in two separate doses given by intramuscular injection, separated by two to six months.

The shingles vaccine is considered an important vaccine for seniors because our immune system weakens as we age. The recommendation for vaccination is based on the potential severity of symptoms and long-term complications.

A shingles vaccine called Zostavax is no longer used in the U.S. as of November 2020. If you received that vaccine, the CDC recommends talking with your doctor about getting the Shingrix vaccine.

The CDCs fact sheet on shingles lists these risks and potential complications:
  • About one in three people will develop shingles at some point in their lifetime
  • More than 99% of people in the U.S. born before 1980 have had chickenpox even if you dont remember it which poses risk for shingles
  • Your risk for getting shingles and complications from it increase as you get older
  • About one in 10 people who get shingles develop ongoing nerve pain
  • Shingles may lead to other complications involving the eye, including blindness rarely, shingles may lead to pneumonia, hearing problems, brain inflammation, or death

Shingrix is more than 90% effective at preventing shingles, but it does not prevent chickenpox.

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