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Does My Health Insurance Cover Shingles Vaccine

What To Know About Shingrix

Medicare & You: Vaccines

The Shingrix vaccine strongly protects against shingles and PHN and has been proven to be more than 90% effective. It is recommended for adults 50 and older. According to the Immunization Action Coalition , efficacy against shingles was 97% for people 5059 years of age, 97% for people 6069, and 91% for people 70 and older. Among people 70+ vaccine efficacy was 85% four years after vaccination.

Shingrix is a two-dose vaccine, and the second dose is given twosix months after the first one. There is no maximum age limit to receive Shingrix. Most primary care doctors and pharmacies offer it throughout the year.

The Shingrix vaccine is a recombinant zoster vaccine it works by boosting your body’s immunity against the zoster virus so that shingles does not develop. The vaccine is safe for most adults, even people with a compromised immune system. Shingrix is recommended for people 19 and older who are immunodeficient or immunosuppressed because of disease or therapy.

Does Medicare Cover Shingrix And The Shingles Vaccine

By Kristen Roloff, quality care coordinator at Network Health Originally published on 10/27/2020 at 8:00 a.m.

As most of us age, we start to become familiar with the names of common medicines and immunizations to help keep us living our best and healthiest lives. One of these immunizations has been getting a lot of attention for its ability to prevent a serious health issue. Were talking about shingles and the vaccine to prevent it, called Shingrix.

What Vaccines Do I Need If I’m Pregnant

Vaccines help protect you and your baby against serious diseases. The CDC recommends you get a whooping cough and flu vaccine during each pregnancy to help protect yourself and your baby. It’s also safe for a woman to get routine vaccines right after giving birth, even if you are breastfeeding. You can get a flu shot any time during pregnancy. You should get Tdap vaccine as early as possible in the third trimester of each pregnancy.

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What Vaccines Do I Need If I’m Traveling Abroad

Travel vaccines depend on where you are going. Contact your doctor or your local health department as early as possible to find out which immunizations you may need. You can visit the Travelers’ Health website for up to date information on immunization recommendations for international travelers or call the CDC information line for international travelers at 1-877-394-8747.

Who Should Not Get Shingrix

Shingles vaccine good for seniors and health

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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Who Should Not Get The Shingrix Vaccine

Shingrix is not recommended for:

  • Anyone with a history of a life-threatening allergic reaction to the vaccine
  • Women who are pregnant
  • Anyone with a current shingles infection
  • Anyone with a moderate to severe illness, with or without fever
  • Those who have never been infected with chickenpox lab testing to verify a lack of previous infection is available, although it is not routinely performed.

If you are not sure if you have ever had chickenpox, the CDC recommends getting the shingles vaccine. Its estimated that more than 99% of Americans born on or before 1980 have had chickenpox, even if they dont remember having the disease.

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.

Recommended Reading: Why Does Shingles Hurt So Bad

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.

Why Does Medicare Not Cover The Shingles Shot

Shingles vaccine is recommended for healthy older adults

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 Long Does It Take Shingles Pain To Go Away

Who Should Get Shingrix

Adults 50 years and older should get two doses of Shingrix, separated by 2 to 6 months. Adults 19 years and older who have or will have weakened immune systems because of disease or therapy should also get two doses of Shingrix. If needed, people with weakened immune systems can get the second dose 1 to 2 months after the first.

You should get Shingrix even if in the past you:

  • Received varicella vaccine

There is no maximum age for getting Shingrix.

If you had shingles in the past, Shingrix can help prevent future occurrences of the disease. There is no specific length of time that you need to wait after having shingles before you can receive Shingrix, but generally you should make sure the shingles rash has gone away before getting vaccinated.

Chickenpox and shingles are related because they are caused by the same virus . After a person recovers from chickenpox, the virus stays dormant in the body. It can reactivate years later and cause shingles.

Shingrix is available in doctors offices and pharmacies.

If you have questions about Shingrix, talk with your healthcare provider.

* A shingles vaccine called zoster vaccine live is no longer available for use in the United States, as of November 18, 2020. If you had Zostavax in the past, you should still get Shingrix. Talk to your healthcare provider to determine the best time to get Shingrix.

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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Private Health Insurance And Vaccinations

Any government-approved vaccines that aren’t included on the pharmaceutical benefits list can be claimed for through some Extras cover plans. The medicine will need to cost more than $41.30. Otherwise, you may need to fund the vaccine privately and you should talk to your GP about this. You can use the tool below to compare Extras plans that might suit you, but you’ll need to check on the provider’s website to see if the policy covers vaccines.

Who Should Get The Shingrix Vaccine

Focus On Herpes Zoster
  • Those who have received the Zostavax vaccine, which is no longer available in the United States
  • Those who either have already had shingles in the past or have never had shingles
  • Those who either have already had chickenpox in the past or do not know whether they have ever had chickenpox
  • Those who have received varicella vaccine
  • Those 19 or older who are or will be immunodeficient or immunosuppressed because of disease or therapy

There is no maximum age for getting Shingrix.

Read Also: What Is Prescribed For Shingles

What Are The Benefits Of The Shingles Vaccine

The shingles vaccines are the best way to protect you from getting shingles. The vaccines have been shown to reduce the risk of getting shingles by 50% for Zostavax® II, and to more than 90% for Shingrix®.

For those who still get shingles after being immunized, the vaccines can reduce pain, including the type of pain that lasts after shingles.

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.

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How Much Does The Shingles Vaccine Cost With Medicare

Most people who are enrolled in Medicare Part D pay less than $50 per dose for Shingrix, according to the vaccine’s manufacturer GlaxoSmithKline. However, your costs will vary based on the plan’s details and if you’ve already met your deductible amount by purchasing other prescription drugs.

For example, some seniors can get the shingles vaccine for free because it’s fully covered by their Medicare Part D or Medicare Advantage plan. Others may have to pay a portion of the cost, such as a $50 copay per shot, or pay full price if the deductible hasn’t been met.

If you don’t have a prescription drug plan or you haven’t met your plan’s deductible, the retail cost for the shingles vaccine is $162 per shot. For the two-dose sequence, the total cost is $324. If the full price of the shingles vaccine is out of your budget, there are several ways you can save money on the vaccine.

How Can You Save On The Cost Of The Shingles Vaccine

What You Should Know About Shingles Vaccines | Johns Hopkins Medicine

These five tips can help you pay less for a shingles vaccine.

  • Visit an in-network pharmacy with a prescription: If you have a prescription drug plan, you could pay less for your vaccine by having it administered at an in-network pharmacy. Getting the shot at a doctor’s office may lead to an additional doctor’s fee for administering the vaccine.
  • Sign up for Medicare Part D or improve your drug coverage: During open enrollment, you can select a prescription drug plan that covers Tier 3 drugs, including Shingrix. Remember to consider the total policy costs for all of your prescriptions. Also, if you receive a low-income subsidy, Medicare Part D plans could be available for free.
  • Get a discount coupon for the shingles vaccine: Pharmaceutical retailers and networks may offer vaccine discounts. Usually, you’ll present the coupon or the drug discount card at the pharmacy to get the savings.
  • Use a state pharmaceutical assistance program: A state program may be available to help you reduce the cost of prescription drugs including the shingles vaccine.
  • Get assistance from the vaccine maker: GlaxoSmithKline offers the GSK Patient Assistance Program for those who meet certain criteria. You may qualify if you earn less than $32,200 annually.
  • Read Also: How Much Is A Shingles Shot

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    Is Shingrix Covered By My Medicare Health Plan

    Yes and no. Medicare Part A and Medicare Part B do not cover the shingles vaccine.

    Coverage, however, may be available through your Medicare Advantage or Medicare Part D plan.

    Medicare Part D is the portion of Medicare covering prescription drugs and typically also covers commercially available vaccines, at varying amounts.

    If you havent met your plans deductible for the year, you may have to pay full price.

    Read Also: Who Do You Get Shingles

    What Is Shingles And How Do You Catch It

    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

    Vaccines Covered By Medicare Part D

    Is Shingrix Covered By Medicare Part F

    Medicare Part D covers all commercially available vaccines needed to prevent illness. You can get Part D coverage through a stand-alone Medicare prescription drug plan or a Medicare Advantage plan that includes drug coverage.

    Vaccines covered by Part D include the following:

    • Shingles vaccine: One-time vaccine given in two shots over two to six months
    • Tdap vaccine : One shot if youve never been vaccinated, and a booster every ten years
    • Other vaccines covered: Vaccines that are “reasonable and necessary” to prevent illness and are not covered by Part B

    Part D may also cover vaccines you may need if you are traveling internationally. Talk with your doctor about your travel plans and ask what vaccines are recommended.

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    Why Is The Shingles Vaccine Recommended

    The Centers for Disease Control and Prevention recommends that healthy adults 50 years and older get two doses of Shingrix two to six months apart to prevent shingles and complications from the disease. The vaccine is typically administered to adults who are 50 years and older. There is no maximum age for getting Shingrix.

    It is also given to those who have received a live zoster vaccine in the past.

    The studies report that two doses of Shingrix will be more than 90 percent effective at preventing shingles and its complication called postherpetic neuralgia.

    The vaccine protects you at least 85 percent of the time for the first four years after vaccination.

    You should get Shingrix even if you have a history as follows:

    • Already had shingles

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