Thursday, July 11, 2024

Does My Insurance Cover Shingles Vaccine

Why Is The Shingles Vaccine Recommended

What You Should Know About Shingles Vaccines | Johns Hopkins Medicine

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

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.

Does Medicare Advantage Cover The Shingles Vaccine

Medicare Advantage plans are private health insurance plans that are approved by Medicare. Medicare Advantage plans must cover the same services as Medicare Part A and Part B, but they can also offer additional benefits. Some Medicare Advantage plans may cover the shingles shot, but it is not required. It is important to talk to your insurance broker or insurer to find out whether your Medicare Advantage plan will cover the vaccine.

Recommended Reading: What Is Shingles Disease And How Do You Get It

What Are The Side Effects Of Shingrix

The most common side effects include pain and inflammation at the injection site, headache, muscle pain, fatigue, stomach discomfort, fever, and shivering, according to GSK.

Allergic reactions are less common but still possible. Watch for signs of an allergic reaction, such as hives, swelling of the face or throat, trouble breathing, rapid heartbeat, dizziness, and weakness. This is considered an emergency, so call 911.

How Much Does The Shingles Vaccine Cost

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The amount you pay for the shingles vaccine will depend on how much your Medicare plan covers. Remember that if you only have original Medicare and no prescription drug coverage through Medicare, you may pay full price for the vaccine.

Medicare drug plans group their medications by tier. Where a drug falls on the tier can determine how expensive it is. Most Medicare drug plans cover at least 50 percent of a drugs retail price.

PRice ranges for the shingles vaccine

Shingrix :

  • Deductible copay: free to $164 for each shot
  • After deductible is met: free to $164 for each shot
  • Donut hole/coverage gap range: free to $74 for each shot
  • After the donut hole: $7 to $8

To find out exactly how much you will pay, review your plans formulary or contact your plan directly.

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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.

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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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.

Medicare Shingles Vaccine Cost

Shingles Vaccine Info

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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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.

What Happens When You Get The Vaccine

As mentioned above, there is one option for the shingles vaccine: Shingrix.

Shingrix, which contains no live virus, is a two-dose vaccine series given in the muscle of the upper arm. The second shot is given two to six months after the first. In clinical trials, it was effective in nearly 97% of adults in their 50s over 97% effective for people in their 60s and over 91% effective for those aged 70 and above. It remains at near 85% effectiveness in all four years following vaccination.18

Shingrix is recommended if youre age 50 or older and have no severe immune problems.19

Effectiveness does come with a cost: In studies, seven in 10 people experienced pain from the Shingrix vaccine, and nearly half have muscle pain or fatigue and some had headaches, shivering, fever and nausea.20 21The CDC suggests avoiding strenuous activities for two to three days after getting either Shingrix shot.

If have previously received Zostavax, you can consider getting Shingrix. The CDC says Shingrix was safe and immunogenic when given five years or later after Zostavax. The agency adds there is no data or theoretical concerns that Shingrix would be any less effective if given sooner. 21

Zostavax was discontinued in 2020 by Merck and is no longer available in the United States.

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Go Through A State Pharmaceutical Assistance Program

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.

Does Medicare Cover The Shingles Vaccine Will I Have To Pay For The Shot

Shingles vaccine good for seniors and health

The CDC recommends people 50 years and older get the shingles vaccine. The shot is widely available and the cost may be covered if you have Medicare Advantage or Medicare Part D. Depending on your plan, you may have to cover a deductible, co-pay, or pay for the shot out of pocket and get reimbursement.

Shingles can cause serious complications, like painful long-term nerve damage. To stay safe from such complications, you may want to consider the new shingles vaccine . An older vaccine once widely administered in the U.S. was less effective and is no longer on the market.

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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

Vaccines And Immunization: What Is Vaccination

Vaccination is a simple, safe, and effective way of protecting you against harmful diseases, before you come into contact with them. It uses your bodys natural defenses to build resistance to specific infections and makes your immune system stronger.

Vaccines train your immune system to create antibodies, just as it does when its exposed to a disease. However, because vaccines contain only killed or weakened forms of germs like viruses or bacteria, they do not cause the disease or put you at risk of its complications.

Most vaccines are given by an injection, but some are given orally or sprayed into the nose.

Vaccines reduce risks of getting a disease by working with your bodys natural defenses to build protection. When you get a vaccine, your immune system responds. It:

  • Recognizes the invading germ, such as the virus or bacteria.

  • Produces antibodies. Antibodies are proteins produced naturally by the immune system to fight disease.

  • Remembers the disease and how to fight it. If you are then exposed to the germ in the future, your immune system can quickly destroy it before you become unwell.

The vaccine is therefore a safe and clever way to produce an immune response in the body, without causing illness.

If you have missed any recommended vaccinations for you or your child, talk to your healthcare worker about catching up.

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Read Also: Where Can Shingles Appear On The Body

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.

Who Should Get The Shingrix Vaccine

Shingles Vaccine Update

The Shringrix shingles shot is recommended for adults age 50 and older.

The Shingrix shingles vaccine is more effective than Zostavax. Shingrix is more than 97% effective in preventing shingles in adults 50 to 69 years old after two doses. The Shingrix shingles vaccine is 91% effective in preventing shingles in adults age 70 and older, according to the CDC.

CDC recommends two doses of the vaccine to prevent shingles and related complications in adults 50 years and older. For adults 19 years and older who have weakened immune systems, the vaccine is also recommended.

There is no age limit for receiving Shingrix, and it is recommended to get the shot if:

  • You have previously had shingles
  • You have received Zostavax
  • You have received the chickenpox vaccine

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What Are Your Chances Of Getting Shingles

Only people who have had chickenpox can get shingles.

Out of 100 people, about 30 may get shingles sometime in their lives. footnote 2 And the risk is higher for people age 50 and older. Older people are also more likely to have severe pain with shingles.

Most people who get shingles will not get it again. But some people get shingles more than once.

How Much Is A Shingles Shot Under Medicare Part D

The good news is that the cost of a shingles vaccine, which comes in two timed doses, is subject to change in 2023.

Starting in 2023, the Inflation Reduction Act will eliminate all out-of-pocket costs for vaccines that the CDCs Advisory Committee on Immunization Practices recommends for adults. That includes the shingles vaccine.

However, in 2022 you may be charged a copayment for the shingles vaccine. This varies from plan to plan. The average Part D copayment for vaccines was $47 in 2020, according to Avalere Health, a health care consulting firm.

If you havent yet met your plans annual Part D deductible, which can be up to $480 in 2022, you may have to pay more for the shot. Shingrix, a vaccine the Food and Drug Administration approved in 2017, runs around $212 per dose.

It replaced Zostavax in November 2020. But even if you received Zostavax before it was retired, the CDC recommends getting inoculated with Shingrix: two doses for adults 50 and older spaced two to six months apart.

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Whats The Cost Of The Shingles Vaccine

According to GlaxoSmithKline, manufacturer of Shingrix, the two-shot series costs people with Medicare Part D an average of $50 per shot.15

As of October 2021, discount-coupon company GoodRx lists Shingrix at around $160, which is about 23% off its reported average retail price of $206.73.16 It indicates that Medicare plans list Shingrix typically in Tier 3 of their formulary. 17

Ultimately, how much your vaccine costs depends on the Medicare prescription plan or Medicare Advantage plan you choose, the vaccine you get and the pharmacy or doctors office where you have it administered.

If the shingles vaccine cost is unaffordable for you, GlaxoSmithKline has a Patient Assistance Program GSK for You that may be able to help you with the cost.

How To Get A Shingrix Discount Without Medicare

Does Medicare Pay For Shingles Shots?

There are a few different ways to receive a discount on the Shingrix vaccine. SingleCares prescription discount card provides instant savings on many prescription drugs, including Shingrix. Medicare recipients cannot use SingleCare and Medicare coverage together, but they can choose to use whichever offers a better deal for them. For those who dont have a Medicare plan that covers Shingrix, SingleCare can provide a discount.

GSK, the manufacturer of Shingrix, offers apatient assistance program for those who dont have insurance coverage. However, there are income guidelines and other eligibility requirements in order to qualify. Those who are enrolled in a Medicare Part D prescription drug plan may still be eligible for the program if their income falls below a certain threshold and theyve spent at least $600 on prescription medications through their plan during the current calendar year.

Lastly, you may qualify for financial assistance through a Medicare program called Extra Help. Extra Help can help Part D consumers lower their Medicare-related costs.

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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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