Traditional Medicare Part B Does Not Cover Some Recommended Vaccines Including Shingles Shots Prescription Drug Plans Include Commercially Available Vaccinations But Are Likely To Require Some Payments From Beneficiaries
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If youre about to make a move to Medicare from your private insurance, you might want to make sure youve had all your shots – especially your vaccination for shingles. Thats because coverage of recommended vaccines under Medicare is more complex than under private health insurance.
Under the Affordable Care Act, private insurers are required to cover all recommended vaccines as preventive care with no out-of-pocket costs to beneficiaries. But under Medicare, different vaccines are covered under different parts of Medicare with inconsistent out-of-pocket costs for beneficiaries.
In short, the shingles vaccine is not covered by Medicare unless you have a Part D prescription drug plan or an Advantage plan with prescription drug coverage even then, youre likely to have out-of-pocket costs.
Medicare Part B covers certain vaccines, including flu and pneumonia, but not others, including shingles. Vaccines covered under Part B are provided to beneficiaries at no cost to them.
If you have a prescription drug plan, Medicare Part D, it will cover other commonly available vaccines, including those for shingles. But even then, Part D is not required to provide cost-free coverage of preventive treatments. What this means is medications and vaccines covered by Part D plans will likely be subject to deductibles and copays, resulting in out-of-pocket costs.
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.
Pain And Complications Of Shingles In Elderly People
Older adults who develop shingles are often surprised at how painful it is. Many say that it is far more painful than the original chickenpox virus that affected them in childhood. Often the skin in the area of the rash continues to hurt even after the rash has healed.
The individual may feel stabbing or throbbing or even weakness. Doctors call this post-herpetic neuralgia, and it can sometimes last for months or even years.
There are also risks for older adults who develop shingles. The blistered area of skin can become infected, requiring antibiotics in addition to antivirals. Such infections can lead to scarring. The rash is also uncomfortable and makes it challenging to rest. When healing takes longer than usual, some individuals can feel despair or even depression. In rare cases, it can lead to encephalitis.
The virus can also be transmitted to other parts of your body, such as your eyes or lips. The herpes virus can cause outbreaks that may affect hearing and vision.
Another thing to be concerned about is contagion. While shingles itself is not contagious, the virus that causes it is. If your spouse has never had chickenpox and has not been vaccinated, he or she could develop chickenpox as an adult. Its important to keep your skin clean and dry and prevent it from rubbing against any other person who could get infected.
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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.
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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Where And How To Get Vaccinated For Shingles
Medicare requires all Part D plans to cover the shingles vaccine. However, since Part D plans have networks, youll want to be sure you get the vaccine at a pharmacy in the plans network.
Do not get the shingles vaccine at your doctors office. Doctors offices dont have the ability to bill Part D plans. Therefore, getting the vaccine at your doctors office could result in you paying the entire bill and having to submit a reimbursement request to your plan.
What Is The Cost Of The Shingles Vaccine Without A Relevant Medicare Plan
You may be able to save on the retail cost of the treatment even if you dont have appropriate Medicare coverage.
Here are three options to look into:
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The GSK Patient Assistance Program helps people who have spent more than $600 on prescription drugs in a calendar year and meet specific income and related requirements.
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State pharmaceutical assistance programs can reduce the cost of the shingles shot if available in your area.
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Its possible to get the vaccine for less than the retail costs by taking advantage of retailer discounts.
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Vaccines At Pharmacies Covered
Vaccines will be covered at in-network retail pharmacies. Find an in-network pharmacy at etf.benefits.navitus.com .
Get vaccinated at any in-network pharmacy, using your pharmacy benefit.
- How much does it cost? $0, its free!
- Which vaccines are available? Influenza, Pneumonia, Tetanus, Hepatitis, Shingles, Measles, Mumps, Human Papillomavirus , Pertussis, Varicella, Meningitis
Just show your Navitus card at the pharmacy. If you prefer, you can still get vaccinated at your doctors office using your medical benefit.
If you are considering getting your vaccine/immunization from the pharmacy, here are a few things to keep in mind:
1. Contact the Pharmacy Ahead of Time
Not all pharmacies are able to administer all vaccines/immunizations for various reasons.
2. Make Sure To Use an In-Network Pharmacy
While most pharmacies participate in the Navitus network, and can administer vaccines/immunizations, not all of them do. A claim for a vaccine/immunization will be rejected if you use an out-of-network pharmacy and you will have to pay the full cost. If the pharmacy you prefer to use for your vaccine/immunization is not in the Navitus network , contact your health plan to see if they will cover your claim through the pharmacy under the medical benefit.
To find a in-network pharmacy contact Navitus at 1-866-333-2757 or visit them online at www.navitus.com.
3. Bring Your Navitus ID Card With You
Home / FAQs / Medicare Coverage / Medicare Coverage for Shingles
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Why Is It So Important To Fully Understand My Medicare Coverage
Having an in-depth understanding of your Medicare health insurance coverage is vital to ensuring that you are always able to receive the highest-quality care possible. You should always take care to ensure that you are making the most of your Medicare coverage by getting the doctor-recommended vaccines you need.
At MedicareInsurance.com, we are ready, willing, and able to help you understand your current coverage and assist you in researching and comparing other, more comprehensive options that may be available to you. To get started today, simply reach out to us online via our free online chat feature, or call us today at 950-0608.
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What Is A Medicare Copay
A copay is an out-of-pocket cost you can expect to pay for certain services. Typically, copays will apply to visits with physicians, specialists, and prescriptions. Depending on your insurance plan, copay amounts can range from $10 $45 per doctor visit. Medicare Part C and Part D charge copayment amounts for prescription and medical services.
Why Doesn’t Medicare Cover The Shingles Vaccine As Free For All Seniors
Many people think that a vaccine that’s recommended by the CDC for those over age 50 would be fully covered by Original Medicare. However, there are a few reasons why you may end up paying hundreds of dollars for the two-dose regimen.
- Medicare coverage levels: Some Medicare drug plans have better cost-sharing benefits than others, and how much you pay for the shingles vaccine depends on the plan you choose.
- Pharmaceutical classification: Medicare classifies the Shingrix vaccine as a part of its pharmaceutical coverage, meaning it would fall under Medicare Part D coverage rather than Part A or Part B. In contrast, most private health insurance, either through an employer or through the marketplace, classifies the shingles vaccine as a part of its free preventative coverage.
- Type of pharmaceutical: Shingrix is a Tier 3 drug made by GlaxoSmithKline, and there isn’t a generic alternative. This could mean that your out-of-pocket costs are higher than for other medications.
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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.
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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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.
What Should I Do If I Have Shingles
If you think you may have shingles, see a doctor as soon as possible and get a professional diagnosis. While some cases are mild and may clear up on their own without treatment, other cases can cause severe pain and require medication to manage.
Its also important to take steps to avoid spreading the virus. The Centers for Disease Control recommends keeping the rash covered and washing your hands often. Avoid touching the rash as much as possible and avoid contact with people who may be at risk, including:
- Premature infants
- Pregnant women who have not had chickenpox or been vaccinated for it
- People with HIV or weakened immune systems due to cancer treatment, organ transplant, or immunosuppressive drugs
Your doctor may recommend antiviral drugs, or simply treating the rash with over-the-counter medication such as calamine lotion to soothe the pain of the blisters. Treatment can reduce the pain and duration of the symptoms, but doesnt cure the disease altogether.
For many seniors, the most painful part of shingles isnt the rash, but post-herpetic neuralgia, which can last a year or more in some cases. Although not everyone who gets shingles will experience post-herpetic neuralgia, it can have a big impact on those that do. Some people develop chronic pain that lasts for years and affects their quality of life.
Read Also: How Long Does Shingles Pain Usually Last
Can You Get The Shingles Vaccine For Free
The shingles vaccine is manufactured by GlaxoSmithKline Biologicals, a pharmaceutical company. GSK has a patient assistance program that may provide the vaccine to you at no cost if you meet these eligibility criteria:
- You dont have prescription drug coverage or a Part D plan and have spent at least $600 during the calendar year
- You are an adult, age 19 or older
- You live in the U.S., Puerto Rico, or the District of Columbia
- You dont qualify for Puerto Ricos Government Health Plan
- Your maximum monthly gross income does not exceed certain limits, depending on where you reside and your household size
- You apply through your health care provider, who will register for the patient assistance program and submit your application
Meningococcal Vaccine Also Available
A meningococcal vaccine is not recommended for all adults. This vaccine may be recommended for you if you have certain risk factors due to your age, health, job, or lifestyle. Talk to your doctor or pharmacist to see if you need this vaccine.
This vaccine is available through local pharmacies as well as in a doctors office.
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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.
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.
Also Check: What Foods Not To Eat With Shingles
Does Medical Insurance Cover The Shingles Vaccine
Brand-name SHINGRIX is paid for by most private insurance carriers. Many of the generic vaccines are also covered, since the likely cost of managing a shingles outbreak and the likelihood of complications is more of a risk than the comparatively low cost of prevention.
Not all insurers pay for SHINGRIX, however, so it is always best to consult with a plan representative before scheduling a course of shingles vaccines.
What Vaccines Does Medicare Part D Cover
Medicare Part D is prescription drug coverage for Medicare beneficiaries. Medicare Part D coverage is offered through private insurance companies through either a stand-alone Part D Prescription Drug Plan or a Medicare Advantage plan with prescription drug coverage.
According to the Department of Health and Human Services, Medicare Part D plans cover all vaccines that are:
- Commercially available
- Reasonable and necessary to prevent illness
- Not covered by Medicare Part B
While Medicare Part B generally covers most vaccines that Medicare patients need, Medicare Part D generally covers vaccines that Medicare Part B does not cover. This would include the shingles vaccine. All Medicare Part D plans are required to cover the shingles vaccine and its administration.
To see if travel vaccines are covered by your Medicare Part D plan, check with the planâs formulary, or list of covered drugs. A new preventative vaccine may not specifically appear in the Medicare Part D plan formulary but the plan may still cover the vaccine.
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