Does Medicare Cover The Shingles Vaccine
- The Centers for Disease Control and Prevention recommends healthy adults age 50 and older get the shingles vaccine.
- Original Medicare wont cover the vaccine.
- Medicare Advantage or Medicare Part D plans may cover all or a portion of the shingles vaccine costs.
As you get older, youre more likely to get shingles. Fortunately, there is a vaccine that can prevent the condition.
Medicare Part A and Part B wont cover the shingles vaccine. However, you may be able to get coverage through a Medicare Advantage or Medicare Part D plan.
Keep reading to find out how to get Medicare coverage for the shingles vaccines or get financial help if your plan doesnt cover the vaccine.
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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.*
Guidance From The Department Of Health
NOTE: Effective August 1, 2020, all immunization records turned in to schools or child care centers are required by state law to be medically verified. Your child cant attend until you provide these records.
Immunization records must be turned in to the school or child care on or before the first day of attendance. Records turned in to the school or child care must be from a health care provider, or you must attach paperwork from a health care provider to your handwritten form that shows your childs records are accurate. Your child cant attend school or child care until you provide these records.
More information about the revised immunization requirement rules for school and child care can be found on the DOH School and Child Care Immunization webpage.
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Where Can You Get Your Shots And Vaccines
If you have health insurance, choosing an in-network provider or a retail clinic that participates in your insurance plan can help you keep costs lower. You can get shots from an out-of-network provider, but you may be asked to pay the full price.
If you have a CareFirst health insurance plan, learn more about what vaccines are covered in the Summary of Preventive Services or ask Member Services any questions you may have.
If you are a member of another health plan, or are comparing available benefits, ask your health insurers Member Services office what vaccines are covered with your health insurance.
Brief History Of Medicare Vaccine Coverage
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.
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What Matters Most To You
Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.
Reasons to get a shingles vaccine
Reasons not to get a vaccine
I want to lower my chances of getting shingles.
I would rather take my chances without getting a vaccine.
I’m afraid of the pain that shingles can cause.
I’m not afraid of shingles pain.
Getting shots doesn’t bother me.
I don’t like getting shots.
Does Medicaid Cover Vaccines For Adults
In addition to the COVID-19 vaccine, the CDC recommends 13 vaccines for adults:
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Tetanus, diphtheria, pertussis
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Meningococcal A, C, W, Y
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Meningococcal B
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Haemophilus influenzae type B
Under Medicaid, coverage for these vaccines, and others, depends on the policies of the state you live in. A recent study found that 22 out of 51 state Medicaid programs covered all 13 recommended vaccines.
For those who live outside of those states, there may be free and low-cost vaccine options that can help. Or, if you have coverage but the cost is still too high, a coupon, like those available from GoodRx, may help you save money.
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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.
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 Much Regional Difference Is There Between States As To Whether Medicaid Covers Adult Vaccines
It varies, but most states cover at least one of the recommended adult vaccines. Some only cover flu vaccines for adults.
Coverage varies widely depending where you live. Among the majority of states that offer at least some coverage, it can range from coverage for both kids and adults to an age limit that caps out at 19 or 20 years old.
So, in some areas, older Americans looking for a shingles vaccine might find it difficult to get coverage. That can be problematic given that Shingrix, the CDC-recommended shingles vaccine, costs about $200 a dose out of pocket and requires two doses. Its now also approved for use in immunocompromised adults.
Who Should Not Get The Shingles Vaccine
- Anyone who has had a serious allergic reaction to this vaccine in the past, or to any component of the vaccine: Varicella Zoster Virus gE Plant extract: Quillaja saponaria Molina fraction 21 Bacterial extract: 3-0-desacyl-4-, monophosphoryl lipid A Powder : dipotassium phosphate, polysorbate 80, sodium dihydrogen phosphate dehydrate, sucrose Suspension: dioleoyl phosphatidylcholine, cholesterol, disodium phosphate anhydrous, potassium dihydrogen phosphate, sodium chloride. Stopper is butyl rubber, not natural rubber latex
- Anyone who has had a case of shingles in the past year.
- Anyone who has had the other shingles vaccine, Zostavax®, in the past year.
- Anyone with a high fever or moderate to severe illness should wait until they feel well.
- Anyone with a bleeding disorder should tell their health care provider since it is an intramuscular injection.
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Are Video Visits With A Primary Care Doctor Online Covered By Molina Healthcare
Most insurers provide coverage for video visits at the same cost as in-person visits. You can search on Zocdoc specifically for Doctors in Nashville who accept Molina Healthcare for video visits by selecting your carrier and plan from the drop-down menu at the top of the page. We recommend you check with your insurance carrier directly to confirm your coverage and out of pocket costs for video visits.
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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.
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What About Medicaid Vaccine Coverage For Children
Coverage is more substantial for children: Medicaid covers all recommended vaccines for enrollees younger than 21 years old, under the Early and Periodic Screening, Diagnostic, and Treatment benefit. The federally funded Vaccines for Children program also provides free vaccines for those who might otherwise skip vaccination because of an inability to pay. These coverage options are especially important because up through the age of 18, there are 13 separate vaccines the CDC recommends for most in that age group, many of which require more than one dose.
Fixing Medicare Vaccine Coverage Once And For All
Nonetheless, barriers to vaccine access remain for seniors due to the separate benefit part placement of vaccines in Part B and D. In seeming acknowledgment of the above problem, Congress acted rapidly to provide for coverage of COVID-19 vaccines without cost sharing under Part B when it passed the Coronavirus Aid, Relief, and Economic Security Act in March 2020, a full eight months before the first vaccine was authorized for emergency use.
As early as 2007 and as recent as 2021, the Medicare Payment and Access Commission recommended moving the coverage of vaccines from Part D to Part B. In the 2007 report, MedPAC foresaw the challenges stemming not only from beneficiary OOP costs under Part D, but also the challenges of physician out-of-network status under Part D. While pharmacists have long been permitted to roster bill vaccinations under Part B, easing the hurdle of split benefit part placement, physicians continue to face difficulty in offering Part D vaccines. Because they are out of network, this makes it difficult to ascertain coverage and cost sharing information. This may lead to patients paying the full cost of vaccines up front and seeking reimbursement under Part D later. This exacerbates the already burdensome financial requirements that result in lagging adult vaccine offerings in physician offices.
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What Parts Of Medicare Cover The Shingles Vaccine
Original Medicare Part A and Part B doesnt cover the shingles vaccine. However, there are other Medicare plans that may cover at least part of the costs. These include:
- 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.
What Are The Side Effects Of Vaccines
Most side effects from vaccines are minor, if they occur at all. Ask your doctor or pharmacist about the reactions that could occur. They may include:
- Redness, mild swelling, or soreness where the shot was given.
- A slight fever.
- Drowsiness, crankiness, and poor appetite.
- A mild rash 7 to 14 days after chickenpox or measles-mumps-rubella shots.
- Temporary joint pain after a measles-mumps-rubella shot.
Serious reactions, such as trouble breathing or a high fever are rare. If you or your child has an unusual reaction, call your doctor.
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Measles Mumps And Rubella
This is important if your child never got this shot.
This shot protects against measles, mumps, and rubella. There is a measles, mumps, rubella, and varicella shot that also protects against chickenpox . It can be substituted for either or both doses of MMR in children ages 12 months to 12 years.
Who should get it?
- If your child did not get either or both doses, he or she should try to get immunized at age 11 or 12.
- Some children may need another dose if your community has had a recent mumps outbreak. Ask your health department if your child will need another dose.
This shot does not necessarily reduce the risk of getting pneumonia. But it can prevent some of the serious complications of pneumonia, such as blood infections .
Who should get it?
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.
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What Is Shingles / Herpes Zoster
- Shingles, also known as herpes zoster, is caused by the same virus as chickenpox. After chickenpox blisters heal, the herpes zoster virus stays, hiding in the bodys nerve cells.
- The virus may be inactive for many years, but for unknown reasons, it can become active again and cause shingles. It can happen to anyone who has had chickenpox, but the risk increases as you get older, especially if you are over 50 years of age two thirds of shingles cases occur over the age of fifty.
- Nearly one in three Canadians develops shingles during their lifetime.
- Shingles causes a painful, blister-like rash that usually appears on one side of the body or face. Up to 4 days before the rash appears, there is often pain, itching or tingling at the site.
- The blisters scab over in 3 to 5 days and can last for 2 to 4 weeks. You might also have a fever, chills, headache and upset stomach.
- In addition to the pain from the rash, the underlying nerve pain caused by shingles has been described as burning, throbbing and/or stabbing. It can last for months or years.
- People with shingles may have other complications, including scarring, bacterial skin infections, weakness, muscle paralysis and loss of hearing and/or vision.
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