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.
Do I Need A Prescription For A Shingles Vaccine
Once you have a Medicare insurance plan that covers the shingles vaccine, youll need to find out whether a prescription is necessary. This is dependent on where you get vaccinated. You wont need a prescription if you get vaccinated at your doctors office.
Some pharmacies that provide vaccines do so under the standing order of a supervising physician. This is convenient for patients because it saves them a trip to the doctors office to acquire a prescription before receiving the vaccine. You may need to call your pharmacy to see how they handle shingles vaccine orders.
If your pharmacy requires a prescription, youll need to contact your medical provider first. They may want to see you in the office beforehand, but not always. Sometimes, the doctor may give you the shingles vaccine at your appointment.
Once you have the prescription in your possession, the remaining steps are pretty straightforward. Take the prescription to a pharmacy in your plans network to be filled. A pharmacist will administer the vaccine in their clinic area.
Its possible to save money on shingles vaccines with a SingleCare pharmacy savings card. SingleCare coupons can help uninsured or underinsured patients get shingles vaccines at a discounted price.
RELATED: Find a pharmacy near you
What Vaccines Does Medicare Part D Cover
Medicare Part D is prescription drug coverage for Medicare beneficiaries. Medicare Part D coverage is offered through private insurance companies through either a stand-alone Part D Prescription Drug Plan or a Medicare Advantage plan with prescription drug coverage.
According to the Department of Health and Human Services, Medicare Part D plans cover all vaccines that are:
- Commercially available
- Reasonable and necessary to prevent illness
- Not covered by Medicare Part B
While Medicare Part B generally covers most vaccines that Medicare patients need, Medicare Part D generally covers vaccines that Medicare Part B does not cover. This would include the shingles vaccine. All Medicare Part D plans are required to cover the shingles vaccine and its administration.
To see if travel vaccines are covered by your Medicare Part D plan, check with the planâs formulary, or list of covered drugs. A new preventative vaccine may not specifically appear in the Medicare Part D plan formulary but the plan may still cover the vaccine.
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Is The Shingles Shot Free For Seniors
The shingles vaccine is not free for all seniors, and how much you pay depends on your Medicare Part D plan or your Medicare Advantage prescription drug benefits. Seniors who don’t have a prescription drug plan will have to pay full price for the shingles vaccine or use a cost-saving method to get the vaccine at a discounted price.
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What Parts Of Medicare Cover The Shingles Vaccine
- Medicare Part C. Medicare Advantage is a plan you can buy through a private insurance company. It may offer additional benefits not covered by original Medicare, including some preventive services. Many Medicare Advantage plans include prescription drug coverage, which would cover the shingles vaccine.
- Medicare Part D. This is the prescription drug coverage portion of Medicare and typically covers commercially available vaccines. Medicare requires Part D plans to cover the shingles shot, but the amount it covers can be very different from plan to plan.
Making Sure Youre covered
There are a few steps you can take to make sure your shingles vaccine is covered if you have Medicare Advantage with drug coverage or Medicare Part D:
- If your doctor cant bill your plan directly, ask your doctor to coordinate with an in-network pharmacy. The pharmacy might be able to give you the vaccine and bill your plan directly.
- File your vaccine bill for reimbursement with your plan if you cant do either of the options above.
If you have to file for reimbursement, youll have to pay the full price of the shot when you get it. Your plan should reimburse you, but the amount covered will vary based on your plan and if the pharmacy was in your network.
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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What Is The Cost Of The Shingles Vaccine With Medicare Part D
Since every insurance plan is different, each Part D plan provides varying degrees of coverage for the shingles vaccine. Some plans may place the vaccine in Tier 1 while others may put it under Tier 3 . Some plans may also have a deductible, meaning 100% of your vaccination or drug costs are on you until you meet the dollar amount specified by your insurance plan.
The best way to know how much a shingles vaccine may cost you is to call your insurance provider and ask.
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.
Read Also: What Can A Doctor Do For Shingles
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.
Cdc Shingles Vaccine Recommendations
The Centers for Disease Control and Prevention recommends Shingrix vaccination for everyone 50 years and older and those 19 years and older who have weakened immune systemseven if you have already had shingles, if you had another type of shingles vaccine, and if you dont know whether or not youve had chickenpox in the past.
You should not get the vaccine if you have a severe allergy to any of the components, currently have shingles, or you have lab tests that definitively show that you do not have antibodies against the varicella-zoster virus. In that case, you may be better off getting the varicella vaccine instead. Also, those who are pregnant should consider delaying vaccination with Shingrix until after delivery.
Read Also: How To Figure Out How Many Shingles You Need
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:|
Shingrix is more than 90% effective at preventing shingles, but it does not prevent chickenpox.
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.
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B Covers 2 Types Of Services
- Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice.
- Preventive services: Health care to prevent illness or detect it at an early stage, when treatment is most likely to work best.
You pay nothing for most preventive services if you get the services from a health care provider who accepts
Get Help With Medigap Coverage For Shingles
If you get shingles, you could have a long road to recovery and significant out of pocket expenses for doctor bills. A Medigap plan helps by paying the portion of your bill that Medicare doesnt pay.
At MedicareFAQ, we can answer all your questions about Medigap and help you find an affordable plan.
To get started, give us a call at the number above. Or, fill out our form
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Does Medicare Cover Shingles Vaccines In 2022
Shingles is a viral infection caused by the varicella-zoster virus . It produces a painful rash with fluid-filled blisters and typically shows up on one side of the body. The same virus that causes chickenpox causes shingles. Anyone who has had chickenpox in the past is at risk of getting shingles.
Shingles is a painful rash that occurs along the distribution of a nerve, called a dermatome, says Erum N. Ilyas, MD, a fellow of the American Academy of Dermatology and founder of AmberNoon. The virus lays dormant in the nervous system. Immunity likely plays a role in preventing the virus from reactivating. When immunity is low, the virus replicates and spreads down the nerve causing pain, inflammation, and blistering.
The Centers for Disease Control and Prevention recommends that adults older than 50 get the shingles vaccine. Shingles can cause long-term nerve pain and nerve damage. Getting two shingles vaccine doses two to six months apart has proven to be very effective at preventing shingles.
Why Do You Need The Shingles Vaccine
In a word: pain. Shingles commonly appears as a rash, usually across one side of your chest, abdomen or face. What starts as itching or tingling becomes an extremely painful band of blisters. These usually scab over in seven to 10 days and clear up in two to four weeks.4
Shingles is most common among people over the age of 50, so the Centers for Disease Controls recommends the vaccine for anyone over that age.
People with a weak immune system are at even higher risk. Your immunity may be weakened if you:5
- Are under extreme stress.
Shingles must be active, meaning in the blister phase, to be contagious. You cannot transmit the virus before the blisters appear, nor once they crust over.6 Even if the virus is active, the risk of spreading VZV is low if you keep the shingles rash covered.7
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Does Medicare Cover Shingles Vaccines
Most health insurance companies cover shingles vaccines, and so does Medicare. However, Original Medicare coverage wont cover the vaccines. You must be enrolled in a Medicare Part D drug plan or a Medicare Advantage Plan that includes drug coverage in order to have prescription drug coverage that covers shingles vaccines. Medicare Part A or Medicare Part B , components of Original Medicare, wont cover shingles vaccines.
Other Medicare supplement plans, like Medigaps, dont cover shingles vaccines either.
You can enroll in a Medicare Part D prescription drug plan by itself, or enroll in a Medicare Advantage plan that includes Part A, B, and D coverage. Either of these options will usually cover the Shingrix vaccine.
Every Medicare Part D plan is different and copays or coinsurance may vary from plan to plan. Deductibles also may apply.
Different Medicare Part D plans classify medications and vaccinations into different tiers. What tier your plan puts shingles vaccinations into will determine your copay. The best way to determine the insurance plan thats best for you is to compare formularies to find the one that covers as many of your medications and vaccinations as possible or contact Medicare customer support.
How Does Your Medicare Deductible Affect Your Vaccine Costs
The deductible amount of your Medicare plan affects how much you pay out of pocket before your insurer starts contributing to the cost of your prescription drugs. Depending on how many medications you take, the deductible could affect how much you spend on the vaccine.
Below, we’ll compare how much you’d pay for the shingles vaccine on two plans with different deductibles. In this situation, the person with the MedicareRx Walgreens plan pays less overall, even though they’re paying full price for the shingles vaccine.
Scenario: Shingrix is the only medication needed during the policy
|AARP MedicareRx Walgreens|
|Cost of two doses of Shingrix vaccine||$160 each, for a total of $320, because the deductible hasn’t been met||$45 copay each, for a total of $90|
|Total annual cost of premiums and shingles vaccine||$788||$1,122|
In the example above, the AARP MedicareRx Walgreens prescription drug plan has a $455 deductible for Tier 3 drugs like the shingles vaccine. That means if you haven’t already met your deductible, you would pay full price for the vaccine, which would be $320 for two doses. The plan costs $38.60 per month for someone living in Charlotte, N.C. If the shingles vaccine is the only Tier 3, 4, or 5 drug needed during the policy year, your total annual spending would be $788.