What parts of Medicare cover the shingles vaccine?
Original Medicare â€” Part A (hospital coverage) and Part B (medical coverage) â€” doesnâ€™t 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 (Part C) 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 â€œcommercially available vaccines.â€ Medicare requires Part D plans to cover the shingles shot, but the amount it covers can be very different from plan to plan.
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:
- Call your doctor to find out if they can bill your Part D plan directly.
- If your doctor canâ€™t 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 canâ€™t do either of the options above.
If you have to file for reimbursement, youâ€™ll 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.
How much does the shingles vaccine cost?
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 drugâ€™s retail price.
Shingrix (given as two shots):
- 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 planâ€™s formulary or contact your plan directly.
How does the shingles vaccine work?
Currently, there is only one vaccine available that has been approved by the FDA to prevent shingles. It is a recombinant zoster vaccine with the brand name Shingrix.
The FDA approved Shingrix in 2017. Itâ€™s the CDCâ€™s recommended vaccine for shingles prevention. The vaccine contains inactivated viruses, which makes it more tolerable for people with compromised immune systems.
Unfortunately, Shingrix is often on backorder due to its popularity. You may have a hard time getting it, even if your Medicare plan pays for it.
What is shingles?
Shingles is a painful reminder that herpes zoster, the virus that causes chickenpox, is present in the body. An estimated 99 percent of Americans 40 years and older have had chickenpox (although many donâ€™t remember having it).
Shingles affects about one-third of people whoâ€™ve had chickenpox, leading to burning, tingling, and shooting nerve pain. The symptoms can last for 3 to 5 weeks.
Even when the rash and nerve pain go away, you can still get postherpetic neuralgia. This is a type of pain that lingers where a shingles rash begins. Postherpetic neuralgia can cause the following symptoms:
- problems completing daily activities
- problems sleeping
- weight loss
The older you are, the more likely you are to have postherpetic neuralgia. Thatâ€™s why preventing shingles can be so important.