Does Medicare Cover the Shingles Vaccine?
Does Medicare Cover the Shingles Vaccine? Herpes zoster, or shingles, is a viral infection caused by the same virus as chickenpox – the varicella-zoster virus (VZV). Even if you’ve had chickenpox you can get shingles at some point in your life because the virus stays in the nerve cells until reactivated.
Medicare Benefits Solutions
Jul 3, 2021
A shingles infection causes a painful rash on the body, generally in a single, localized area on one side. The rash is red and consists of blisters that are full of virus particles. It isn’t possible to infect another person with shingles, but someone can get chickenpox if they come into contact with the virus particles in the blisters.
Even though most people have an inactive presence of the VZV in their nerve cells, it doesn’t mean they’ll experience a shingles infection. Some of the risk factors for reactivation are advanced age, a weak immune system, or have had a case of chickenpox before 18 months old. If you have a strong and healthy immune system, the VZV virus remains suppressed. However, if you become immunocompromised, the chances of getting a shingles infection increase.
Today, the only means of protection against shingles and any possible complications from infection is a shingles vaccine. Shingrix and Zostavax are two brands of recombinant zoster vaccines that are available today. The CDC recommends that adults who are 50 years old and over get two doses of the vaccine over a period of two to six months from their doctor or pharmacist.
For people who are over 50, getting the shingles vaccination is important for a healthy life. That’s why it’s vital to have information about whether your Medicare insurance benefits cover the cost of the vaccine.
Does Medicare cover the shingles vaccines?
If you have Original Medicare Part A (hospital insurance) and Part B (medical insurance), you have coverage for some vaccines such as flu, hepatitis B, and pneumonia. However, Original Medicare insurance doesn’t offer benefits for shingles vaccines.
To get coverage for your shingles vaccinations, you need to have a Medicare prescription drug (Part D) plan or a Medicare Advantage (Part C) plan that includes this type of coverage.
Medicare prescription drug plans are available for Medicare beneficiaries to purchase from private insurance providers that are Medicare-affiliated. Every Part D plan has a list of prescription drugs, called a formulary, that are included in the benefits.
As of now, Medicare requires all stand-alone Part D and Medicare Advantage plans that include prescription drug coverage to offer at least one type of the available shingles vaccines. The amount you pay out-of-pocket for your vaccine depends on what your plan provider charges as a copayment and deductible. If you haven’t met your plan’s deductible for the current year, you may end up paying full price for your vaccine.
If you have a Medicare Advantage plan, your provider may require that you use health care providers, facilities, and suppliers that are included in the plan’s set network. In some cases, if you go outside the network you don’t get coverage. Your plan provider can give you details about providers within the network if you aren’t sure.
How much does a shingles vaccine cost with and without Medicare coverage?
Your final cost for your shingles vaccines depends on what your Medicare insurance policy covers and the amount of the copayment. All prescription drug plans categorize the drugs and vaccines they cover on the formulary into tiers, and each tier carries a different copayment amount. For example, tier-one drugs have the lowest copayment and include most generic drugs.
Tier two drugs are those that are preferred, brand-name prescription drugs that have a medium copayment. Non-preferred, brand-name drugs with a higher copayment are on tier three, and high-cost prescription drugs with the highest copayment are on the specialty tier.
If you don’t have coverage through a Medicare-affiliated prescription drug plan and you have to pay 100 percent of the price for your shingles vaccine, prices vary depending on location. However, the national average cost for one dose of Shingrix in the United States is $190.00. For full coverage, you need to have two doses within six months of each other.
Does Medicare Cover the Shingles Vaccine? To find out how much you have to pay for your vaccine dose, you can read your plan’s formulary or call a representative of your plan’s provider. You can get your vaccine administered either by a health care provider in a medical facility or by a licensed pharmacist. If you have a Part C plan, make sure you use a provider that is within the plan’s network if required.