Medicare Payment For Shingles Vaccine

Who Should Not Get Shingrix

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.

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.

Vaccines Covered By Medicare Part D

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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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.

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

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.

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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.

What Are My Options For The Shingles Shot

The two options for the shingles shot are Zostavax and Shingrix. Zostavax, according to the Mayo Clinic, protects against shingles for about five years. Itâs a live vaccine given as a single shot in the upper arm. The Zostavax shingles shot is recommended to adults age 60 and over which reduces the risk of developing shingles by 51%, according to the Centers for Disease Control and Prevention .

Studies suggest that Shingrix offers protection against shingles for more than five years. Itâs a nonliving vaccine given in two doses. 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.

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Why Do You Need Shingles Shot

For older Americans, the shingles vaccine is an important way to protect against the herpes zoster virus. The virus can cause a painful rash and blisters. It can also lead to serious complications, such as pneumonia, brain damage, and even death.

It is recommended that adults over the age of 60 get the vaccine. If you are over the age of 60, talk to your doctor about whether the shingles vaccine is right for you and let an insurance broker find the best Medicare shingles vaccine plan.

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Do I Have To Pay For Vaccines With Medicare

You pay nothing for vaccines covered by Part B flu, pneumonia and Hepatitis B as long as your provider accepts Medicare.

Your cost for vaccines covered by Part D will depend on your specific plan. You may pay a copay or coinsurance, but it will depend on your plan and the provider.

The location where you get vaccinated may also affect your cost. For example, your costs may be lower if you get a vaccine at a pharmacy versus in a doctors office.

Does Medicare Advantage Cover A Shingles Vaccine

If you have a Medicare Advantage plan with prescription coverage, then the shingles vaccine will be covered. If you dont have prescription coverage, youll have to pay for the vaccine yourself.

As with traditional Medicare, the cost of the vaccine can vary by plan. Youll save money by getting your vaccine from a pharmacy in your plans network.

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How To Find Out If Your Medicare Plan Covers Shingles Vaccines

If you have a Medicare Advantage plan with prescription drug coverage, or a standalone Part D plan, then you should be covered for the shingles vaccine in many circumstances. But how you find out how much of the cost your plan covers?

First, find out how your insurer categorizes the shingles vaccine on their formulary. A lot of plans list Shingrix on Tier 3 drug as a preferred brand-name drug. Unfortunately, there isnt a generic version of the vaccine, so there isnt much you can do about that.

Second, look up your copay for that tier of drugs. It could range from $0 to over $100 depending on your plan, and depending on whether you get the vaccine in or out of network.

Also, if you havent yet reached the annual deductible for your insurance plan yet, youll have to pay the entire amount out of pocket .

So, while all Part D plans are required to cover the shingles vaccines, the amount that they cover varies widely between insurers.

If youre just signing up for a Medicare plan and expect to get the shingles vaccine within the next year, you can choose a plan that has a lower copay. Or, you can switch plans during the annual open enrollment period to find one that covers it at a better price.

If you currently have private insurance, then it may be a good idea to get the vaccine before enrolling in Medicare, since many private insurers cover it under preventative care.

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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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.

You Can Get A Shingles Vaccine Two Ways:

At the pharmacy. Youll still need a doctors prescription, but once thats been transmitted, you can get the shot at a retail pharmacy.

Most major chains and some independent pharmacies can administer the vaccine. Just make sure to use a store in your drug plans network so that it can bill your plan directly and youll owe just the copayment.

At the doctors office. If youre vaccinated in a doctors office, check whether it can bill your drug plan directly or works with a pharmacy that can do so. If so, it will work as mentioned above, with you owing a copayment. If not, you may need to pay the full cost up front and then file a claim for reimbursement from your plan.

Remember that the doctors fee for administering the vaccine may exceed your plans allowable charge, in which you case youre on the hook for the difference. It pays to check beforehand.

Editor’s note: This article was originally published on Jan. 1, 2014. It has been updated with the latest information regarding Medicare coverage in 2020.

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How Much Will You Pay For Shingles Vaccines

You can find the shingles vaccine on your Part D plan formulary or listing of covered medications. Check to see into which tier the vaccine falls the tier will define how much your insurer will pay and how much you will have to pay.14

If your doctors office will provide the vaccination, check to be sure they can bill your plan directly. That way, youll have only the copay. Otherwise, you may have to make the full payment upfront and file with your plan for reimbursement. Also, check to be sure that the doctors fee for administering the shot is covered as part of your plans allowable charge.13

Youll probably pay the least amount out-of-pocket by being vaccinated at a pharmacy thats within your drug plans network. But if you havent met your deductible for the year on your drug plan, you may pay full price for the vaccine.

If you havent had your shingles vaccine yet and youre selecting a Medicare Advantage plan during the Open Enrollment Period, be sure its one of the medications on whatever plan you choose.

Does Medicare Pay For Shingles Shots

Heres the quick answer

Surprisingly, Original Medicare doesnt cover the shingles vaccine, even though it covers other vaccines like the flu vaccine and pneumonia shot.

On the other hand, Medicare Part Dor a Medicare Advantage plan that includes Part D coveragetypically does cover the vaccine.

The devil is in the details

Every Part D plan is different, so your copay for a shingles vaccine could vary from one insurance plan to another. For this reason, its always good to check your plans formulary to see which vaccines they cover and which tier those medications fall under.

Part D covers a lot more than the shingles vaccine, providing coverage for prescription medications. If you need the shingles vaccine and prescription drug coverage, see our guide on how to find the best Part D plan for you, or learn more about Part D first.

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Does Medicare Cover Shingrix Or Zostavax

Many Medicare Part D and Medicare Advantage plans provide coverage for Shingrix and/or Zostavax.

• Medicare Part D plans provide coverage exclusively for prescription drugs.
• Medicare Advantage plans provide coverage for all Medicare Part A and Part B benefits, and most Medicare Advantage plans also cover prescription drugs. Some plans also offer dental, vision and hearing benefits, along with a range of other benefits that Original Medicare doesn’t cover.

Both Medicare Advantage plans and Part D plans are sold by private insurance companies.

Medicare Part B Coverage For Shingles Treatment

Shingles appear as a painful rash on one side of your body. You may feel pain, itching, or tingling before the rash develops, and you may also have a fever, headache, or upset stomach. The rash turns into blisters that usually scab up within a week to 10 days.

If you believe you have shingles, its best to see a doctor right away. Prescription antiviral medications can shorten the illness and make it less severe, but they work best if you start taking them as soon as possible after the rash appears. If your pain is severe, your doctor may also prescribe pain medication or give you a corticosteroid injection.

Part B covers a visit to a doctor or urgent care center. It also covers any injections you receive at the doctors office. If you have a Medicare Supplement plan, you may not have to pay anything out of pocket to see a doctor for shingles.

If you have a Medicare Advantage plan, Part B will still cover doctor visits and injections. But youll have different costs than if you had Medicare.

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What Are The Complications Of Shingles

The most common and lasting complication of shingles is nerve pain, whats called postherpetic neuralgia , which can last for months or even years, long after the rash has cleared up. According to the CDC, between 10% and 18% of people whove had shingles will develop PHN.

PHN is a stabbing or throbbing pain or weakness where the shingles rash had been. The risk increases with age and the pain lasts longer and is more severe than in younger people.8

In rare cases, shingles can develop into pneumonia, hearing problems, blindness and brain inflammation.9 Only 1% to 4% of people with shingles are hospitalized for complications, though these are typically older adults and people whose immune systems are weak or suppressed, and fewer than 100 people die from shingles each year.10

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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