Tuesday, June 25, 2024

Medicare Part D Shingles Vaccine

What Is Shingles And How Do You Catch It

Relief coming to those on Medicare who can’t afford shingles vaccine

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

How Long Does Shingrix Last

The Shingrix vaccine can remain effective for at least four years in most people and even longer in others. You must get the entire series to be protected against shingles, which includes two separate shots. Even if you have had the infection, getting vaccinated can still offer benefits because it may help reduce the risk of developing PHN.

Shingrix may not protect everyone, but it provides broader protection for older adults whose immune systems are declining with age or disease.

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 licensed insurance agent and a Senior Staff Writer for MedicareAdvantage.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.

His work has been featured in outlets such as Vox, MSN, and The Washington Post, and he is a frequent contributor to health care and finance blogs.

Christian is a graduate of Shippensburg University with a bachelors degree in journalism. He currently lives in Raleigh, NC.

Where youve seen coverage of Christians research and reports:

Plan availability varies by region and state. For a complete list of available plans, please contact 1-800-MEDICARE , 24 hours a day/7 days a week or consult www.medicare.gov.

Recommended Reading: What Brand Shingles Are Best

Who Should Not Get The Shingrix Vaccine

Those who should not receive Shingrix are:

  • People with allergic reactions to any part of the vaccine
  • People with allergic reaction after a dose of Shingrix.
  • People who currently have shingles.
  • Pregnant women should wait to get Shingrix.

If you have a cold or any other minor illness, you can get Shingrix, however if you have moderate or severe symptoms, with or without fever, you should wait till recovering before getting the vaccine.

You Wont Pay For Medicare Vaccines In 2023

Does Medicare Pay For Shingles Shots?

You won’t pay for Medicare vaccines in 2023.

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For you, a vaccination is a vaccination it protects you against something. But, under Medicare, all vaccines are not equal and that means you probably paid more for some than for others.

The coverage for a vaccine depends on the part of Medicare under which it falls.

Part B, medical insurance, covers most vaccines that Medicare beneficiaries need. There is no copayment for those that every Medicare beneficiary should get, specifically:

Those who chose Original Medicare can get the vaccine from any doctor or pharmacy that accepts Medicare assignment. Medicare Advantage plan members should visit a doctor or pharmacy in the plans network. No matter the type of Medicare you have, there is no deductible, copayment or coinsurance.

Public service announcement about the flu

During the 2020-2021 flu season, flu was practically nonexistent. Thats because of all the handwashing, masking, sheltering at home and social distancing we did to control the spread of Covid. The impact of all these practices carried over into the next year with another mild flu season. But that may change this year.

That will change as of January 1, 2023. Just as with the flu, Covid and pneumonia vaccinations, Part D vaccines will not be subject to a deductible and there will be no copayment. Keep these points in mind.

Recommended Reading: How To Help Nerve Pain From Shingles

When Do Blue Cross Blue Shield Medicare Plans Pay For Vaccines

All Blue Cross Blue Shield Medicare Advantage plans must provide all of the same coverage as Medicare Part A and Part B, which together are often called Original Medicare. Most Medicare Advantage plans also offer extra benefits like dental, vision, prescription drug coverage and more, all of which are not covered by Original Medicare.

Four vaccines are covered by Medicare Part B, which means Blue Cross Blue Shield Medicare Advantage plans are also required to cover them:

These shots are covered at no cost to the delivered at a Blue Cross Blue Shield network provider. Additional vaccines are typically covered if a plan member is exposed to a particular danger, such as a tetanus shot after stepping on a rusted nail.

BCBS Medicare Advantage plans that include prescription drug coverage may cover additional vaccines.

Medicare Part D prescription drug plans cover medications including additional vaccines not covered by Medicare Part B. Part D plans cover all commercially available vaccines, except those covered by Medicare Part B, when they are reasonable and necessary to prevent illness. Some of the vaccines that can be covered by a Blue Cross Blue Shield Part D plan include:

Does Medicare Pay For The Shingles Shot

If you have Medicare with a separate Part D plan, your prescription coverage will include shingles shots. Several companies sell prescription plans, and each has its own deductibles, copays, and network of preferred pharmacies.

  • If you get your shot at a preferred pharmacy, your pharmacy will bill Medicare, and youll pay any deductibles or copays.
  • At a pharmacy outside your plans preferred network, youll pay more.
  • If you get a shot at your doctors office, your doctor may be able to work with a pharmacy to bill Medicare directly. Or you may have to pay up-front and ask Medicare to reimburse you. Be aware that your doctors fee for administering the vaccine may be more than your prescription plan will pay.

Often the most cost-effective way to get a shingles vaccine is to get a prescription from your doctor and then go to a pharmacy in your plans network to get your shot.

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Don’t Miss: Schedule Shingles Vaccine At Cvs

Prescription Drug Coverage And Shingles Treatment

Your doctor may prescribe antiviral drugs such as famciclovir, valacyclovir, and acyclovir. These drugs can help the rash heal more quickly and reduce the chance youll suffer serious side effects. If your pain is severe, your doctor may also write you a prescription for pain medications.

Medicare prescription plans typically cover both antiviral and pain medications, though the specifics will depend on your plan. You may have to pay a deductible or copay.

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Your doctor may also suggest over-the-counter remedies such as lidocaine patches and Tylenol. Prescription plans dont cover over-the-counter medications, even if your doctor recommends them.

Whats Shingrix Zostavax And Shingles

Medicare & You: Vaccines

FDA approved in 2017, Shingrix is the leading preventive tool against shingles . Shingles is caused by a once dormant chickenpox virus rearing its ugly head to give you a painful rash that can last for up to four weeks. For some, long-term pain continues even after the rash is gone, a condition known as postherpetic neuralgia.

Since 99% of people in the US have chicken pox by age 40, and since the risk of shingles increases with age, the Centers for Disease Control recommends that every healthy adult over 50 get Shingrix.1 Shingrix is over 90% effective at preventing shingles and postherpetic neuralgia, making it the preferred shingles shot.2 But for those who may be allergic to Shingrix, another shingles vaccine, Zostavax, can be used.

Zostavax may also be covered by Medicare prescription drug insurance , but again, you should check to be sure.

Recommended Reading: How Long Does It Take To Clear Up Shingles

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.

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.

Read Also: How Many Shingles Vaccines Are There

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.

Medicare Part D Coverage Of Immunizations Effective Jan 1 2023

Flu Shot Friday!

The Varicella Zoster virus is commonly called Chickenpox, but did you know it is the same virus that causes Shingles?

People who have had a history of Chickenpox when they were younger have a chance to get Shingles later in life. After having Chickenpox, the virus goes dormant and can be reactivated into Shingles. Shingles is a blistered rash lasting 7-10 days before the blisters are scabbed over and fully clear in 2-4 weeks.

The blistered rash can become painful for most people, where some can develop long term nerve pain. Typically, the rash is a single strip on either the side of the body or face. If a person gets Shingles on the face, it can affect the eye and may cause vision loss. Shingles can happen more than once in your lifetime.

The best way to prevent Shingles and complications of the disease is by vaccinating against Shingles. There is only one Shingles vaccine in the U.S. today, Shingrix. Shingrix is a two-shot series that is spaced out 2-6 months. People over the age of 50 years of age or 19 years and older who have a weakened immune system related to a disease or therapy are eligible to receive Shingrix. Research has shown Shingrix develops strong protection, up to 90%, in healthy people over the age of 50 and can continue to stay strong for at least the first 7 years after the vaccination.

Recommended Reading: Is It Ok To Shingle Over Old Shingles

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.

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.

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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.

Why Do You Need The Shingles Vaccine

Addressing Adult Patientsâ Shingles Vaccine Concerns with Dr. Sandra Leal

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

Read Also: What Can You Use To Stop The Itching Of Shingles

Congress Finally Eliminates Part D Vaccine Cost Sharing: Medicare Coverage Is Still Broken

The Inflation Reduction Act leaves intact a peculiar split in Medicare vaccine coverage that discourages physicians from offering certain vaccines, former Moderna Vice President Richard Hughes argues.

Editors note: Richard Hughes is a member of the firm Epstein Becker Green in the Health Care & Life Sciences practice and a former vice president for Moderna.

In its passage of the Inflation Reduction Act of 2022, Congress has taken the long overdue step of eliminating out of pocket, or OOP, costs for vaccines under Medicare Part D. The OOP prohibition aligns with policies under Medicare Part B and the Affordable Care Act and removes a pharmacy counter barrier that will undoubtedly lead more seniors to be vaccinated against shingles. However, it leaves intact a peculiar split in Medicare vaccine coverage that discourages physicians from offering certain vaccines.

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