Monday, May 16, 2022

Does Medicare Part D Cover Shingrix Vaccine

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Who Should Not Get Shingrix

Medicare & You: Vaccines

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
  • tested negative for immunity to varicella zoster virus. If you test negative, you should get chickenpox vaccine.
  • currently have shingles
  • currently are pregnant or breastfeeding. Women who are pregnant or breastfeeding should wait to get Shingrix.

If you have a minor acute illness, such as a cold, you may get Shingrix. But if you have a moderate or severe acute illness, you should usually wait until you recover before getting the vaccine. This includes anyone with a temperature of 101.3°F or higher.

The side effects of the Shingrix are temporary, and usually last 2 to 3 days. While you may experience pain for a few days after getting Shingrix, the pain will be less severe than having shingles and the complications from the disease.

Medicare Coverage For Shingles

Home / FAQs / Medicare Coverage / Medicare Coverage for Shingles

All Medicare prescription plans cover shingles vaccines. If you believe you may have shingles, Part B pays for a visit to the doctor.

If your doctor prescribes antiviral or pain medications, Medicare prescription drug plans will usually cover them.

In the context below well discuss coverage and costs for everything relating to shingles with Medicare.

How Well Does Shingrix Work

Two doses of Shingrix provides strong protection against shingles and postherpetic neuralgia , the most common complication of shingles.

  • In adults 50 to 69 years old who got two doses, Shingrix was 97% effective in preventing shingles among adults 70 years and older, Shingrix was 91% effective.
  • In adults 50 to 69 years old who got two doses, Shingrix was 91% effective in preventing PHN among adults 70 years and older, Shingrix was 89% effective.

Shingrix protection remained high in people 70 years and older throughout the four years following vaccination. Since your risk of shingles and PHN increases as you get older, it is important to have strong protection against shingles in your older years.

Recommended Reading: Do You Have To Get Medicare At 65

Which Vaccines Do Medicare Advantage Plans Cover

Medicare Advantage plans, sometimes referred to as Part C plans, are offered by private insurers for a set monthly premium. These plans bundle Part A and Part B insurance and usually Part D coverage.

Medicare Advantage plans must cover certain vaccines with no copay when given by a healthcare provider who accepts your insurance. The vaccines usually covered are:

  • Hepatitis A and B

  • Tetanus, diphtheria, and pertussis

  • Varicella

Check with your insurance provider for specific plan details. Avoiding these preventative vaccines can have serious health consequences. Since you can easily get vaccines at your providers office or the pharmacy, making them a priority is worthwhile.

During the lockdown, routine vaccines have dipped substantially. Its important to catch up on immunizations that were missed, Dr. William Schaffner, a professor of infectious diseases at Vanderbilt University Medical Center, tells GoodRx.

Do I Need The Shingles Vaccine And How Much Does It Cost

Does Medicare provide cover for Prevnar

The CDC recommends adults 50 years and older should get two doses of the shingles vaccine. Shingles is a viral infection that can cause several symptoms, including:

  • Nerve pain

  • Pneumonia

  • Other serious symptoms

Two doses of Shingrix will protect you against shingles and postherpetic neuralgia , the most common shingles complication. PHN affects your nerve fibers and skin, leading to burning pain that persists after other symptoms of shingles, such as the rash and blisters, have gone away.

Studies suggest Shingrix was between 91% and 97% effective in preventing shingles after two shots, depending on your age. Since your risk of acquiring shingles and PHN increases as you get older, strong protection against shingles after 50 is important.

Most Medicare Part D cover the shingles shots, as well as Medicare Advantage plans with built-in Part D coverage. Depending on your plan, you may have to pay toward your deductible, a copay, or pay out-of-pocket and get reimbursed later.

If you havent met your plans deductible for the year, youll have to pay full price for the vaccines. If you have to pay upfront, the average retail cost of is about $200 per dose. You need two doses of Shingrix, 2 to 6 months apart.

Read Also: When Can I Enroll In A Medicare Supplement Plan

Have Medicare The Shingles Vaccine Will Cost You

Medicare beneficiaries who are able to get their hands on a dose of the new shingles vaccine, which has been in short supply, may pay more than they expect.

    When Stanley Isenberg learned there was a new shingles vaccine, he set out to find it.

    Having seen how his father suffered with the painful, blistered rash of shingles, he wanted to avoid that fate at all costs.

    Isenberg, a 94-year-old World War II veteran, was prepared to pay. But he was still shocked by the price the pharmacist quoted for the first in the two-shot series: $167.

    “I said, ‘Wow!’ ” Isenberg recalled.

    The pharmacist shrugged. Isenberg chewed on the number, thought about his father, then rolled up his sleeve and replied, “Let’s go.”

    Shingrix, made by GlaxoSmithKline, has been in such high demand since it was released last year that many pharmacies have had a hard time keeping it in stock. But if you’re lucky enough to track it down and you are covered by Medicare, be prepared to pay dearly.

    Under the Affordable Care Act, most private insurance plans are required to cover the vaccine with no copay or coinsurance when administered by an in-network provider.

    “The prices are all over the map,” said Sue Greeno, a Medicare advocate with the Center for Medicare Advocacy in Washington. “I strongly advise people if they’re considering this to check with their plan if it’s on their covered list of drugs.”

    Medicare Drug Plans And The Shingles Vaccine

    Unlike Medicare parts A and B, which are government insurance plans that cover hospital insurance and outpatient medical insurance, respectively, Medicare drug plans are private insurance policies developed by providers that have contracts with the federal government. You might purchase such a policy if you have Original Medicare or a Medigap plan and need prescription drug coverage.

    Also Check: Can I Switch Medicare Supplement Plans

    How To Learn More About Medicare Coverage For Pneumonia Vaccines And Other Preventative Services

    Would you like more information about Medicare coverage for the pneumonia vaccine or other preventative services? Im here to help you:

    • To communicate with me by phone or email, use one of the options below.
    • Use the Compare Plans Now button on this page to get more information about Medicare insurance in your local area.

    New To Medicare?

    Becoming eligible for Medicare can be daunting. But don’t worry, we’re here to help you understand Medicare in 15 minutes or less.

    Where Can I Get Vaccines I Need

    Understanding Medicare Part A

    You can get most vaccines at a pharmacy, doctors office, clinic or community health center. Talk with your doctor about what vaccines you may need. Your doctor or Part D plan provider can also help you understand whether your cost will be affected by where you go to get the vaccines that your doctor recommends.

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    What Are My Options For The Shingles Shot And How Does It Work

    As of November, 2020, there is only one shingles vaccine available in the United States. This goes by the trade name Shingrix.

    Shingrix was approved by the FDA in . It is more than 90 percent effective at preventing shingles and postherpetic neuralgia after two doses of the vaccine.

    An earlier vaccine, Zostavax, is no longer in use in the United States as of November 18, 2020. Zostavax first got FDA approval in 2006. It was about 51 percent effective at preventing shingles and 67 percent effective at preventing PHN.

    Is Shingrix Free For Seniors

    The Shingrix vaccine isn’t automatically free for seniors. However, many seniors will have private health care insurance that covers Shingrix. According to the Shingrix website, the vaccine is included in 90% of private health care plans, with average costs of less than $5 per shot. You may also be eligible for a free Shingrix vaccine if you have Medicare Part D insurance.

    The Affordable Care Act requires that most private health care insurance plans must cover preventative health care, including vaccines, without cost-sharing. This means that many insurers aren’t allowed to charge beneficiaries for vaccines like Shingrix. However, most providers require you to have your vaccine at an in-network facility to get your vaccine free.

    Also Check: What Is Medicare Advantage Part C

    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.

    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.

    Does Medicare Cover The Shingles Vaccine Conclusion

    Medicare prescription plans: Coverage, costs, and criteria

    Original Medicare A and B dont cover the shingles vaccine. However Medicare dictates that whatever Part D plan you have must have coverage, but the costs you would pay under your Part D plan can vary greatly between plans. If you have a Medicare Advantage plan that also has Part D coverage then you will also have coverage. Whether you have a stand-alone Part D plan or your Part D coverage is embedded in your Medicare Advantage plan, you are likely going to need to pay deductibles and copays for the vaccine. An alternative you may want to look at is the online discount programs. I used Goodrx in this blog as an example, but there are many out there to look at.

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    What Steps Can You Take To Make Sure You Are Covered If You Have Medicare Advantage With Drug Coverage Or Medicare Part D

    If you already have Medicare Advantage, or Medicare Part D, contact your provider to check your coverage. Medicare Advantage plans are offered by private companies that Medicare approves.

    If you are not yet on Medicare and want to find a plan that covers the shingles shot, you can use Medicares Find a Medicare Plan tool. This tool allows you to compare Medicare Advantage and Part D plans.

    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.

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    Can You Get Shingles If You Had The Chickenpox Vaccine

    It depends. Anyone who has ever had chickenpox is susceptible to shingles. When the chickenpox virus comes out of hiding and reactivates, it causes numbness, tingling, blisters, and sometimes flu-like symptoms. If you never had chickenpox because you were vaccinated, you run a very low risk of getting shingles.

    Find Medicare Advantage Coverage For The Shingles Vaccine

    Everything You Need to Know About Shingrix | CDC experts

    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 you’ve seen coverage of Christian’s 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.

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    Get Medicare Part D Coverage

    Medicare Part D is an optional benefit you can get if you are enrolled in Medicare. With Medicare Part D, you can get coverage for prescription drugs. Depending on your plan, Medicare Part D may cover both brand-name and generic medication.

    Medicare Part D plans cover all commercially available vaccines, including Shingrix. By purchasing Medicare Part D, you can get coverage for the shingles vaccine.

    According to the Kaiser Family Foundation, the average monthly premium for Medicare Part D was $40 in 2019. However, youll likely have to pay a copayment when you get your shots, too.

    Who Needs The Shingles Vaccine

    According to the Centers for Disease Control and Prevention , the Advisory Committee on Immunization Practices recommends the shingles vaccine for people 50 and older. It is a manufactured inactivated vaccine intended to prevent shingles. The vaccine is administered in two separate doses given by intramuscular injection, separated by two to six months.

    The shingles vaccine is considered an important vaccine for seniors because our immune system weakens as we age. The recommendation for vaccination is based on the potential severity of symptoms and long-term complications.

    A shingles vaccine called Zostavax is no longer used in the United States as of November 2020. If you received that vaccine, the CDC recommends talking with your doctor about getting the Shingrix vaccine.

    The CDCs fact sheet on shingles lists these risks and potential complications:
    • About one in three people will develop shingles at some point in their lifetime.
    • More than 99% of people in the United States born before 1980 have had chickenpox , which poses risk for shingles.
    • Your risk for getting shingles and complications from it increase as you get older.
    • About one in 10 people who get shingles develop ongoing nerve pain.
    • Shingles may lead to other complications involving the eye, including blindness. Rarely, shingles may lead to pneumonia, hearing problems, brain inflammation, or death.

    Shingrix is more than 90% effective at preventing shingles, but it does not prevent chickenpox.

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    More From This Series Insuring Your Health

    If the vaccine co-payment is still too high, it may be worth looking into other Part D plans or signing up for one during the upcoming annual enrollment period, Oct. 15 to Dec. 7. Depending on your other prescription drug needs and coverage, you may be able to find a better deal, Lipschutz says.

    Its worth noting that under the 2010 health care law, people who have new private health insurance plans and those whose plan benefits have changed significantly are eligible to receive, free of charge, vaccines recommended by the CDCs Advisory Committee on Immunization Practices. Plan members who are in their early 60s, therefore, might qualify for a shingles vaccine without a co-pay.

    Q. Do I have to keep my 18-year-old child on my health insurance?

    A. In a word, no. The Affordable Care Act requires insurers to offer to cover adult children of policyholders until age 26, but it doesnt require parents to purchase that coverage, according to an official at the Department of Health and Human Services.

    Q. Whats to stop a teenager from getting her own individual policy once she finds out shes pregnant, if her parents plan wont cover her maternity care?

    A. Although health plans must offer to cover adult children on their parents plans until they reach age 26, insurers arent required to provide them maternity benefits . In that case, a young person or her parents might consider buying an individual policy, as this questioner suggests. But they may run into obstacles.

    Whats The Cost Of The Shingles Vaccine

    Does Medicare offer pharmacy home delivery?

    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.

    Read Also: How Does Medicare Supplement Plan G Work

    Why Is Shingrix So Expensive

    The Shingrix vaccine is relatively expensive, and you should expect to pay around $200 per shot out of pocket. There are several reasons why the Shingrix vaccine is so costly, including local shortages and the fact that the vaccine is a brand-name product.

    Unlike the influenza, COVID-19 and pneumococcal vaccines, which Original Medicare may cover, Medicare classes Shingrix as a prescription drug even though the CDC recommends it for adults over 50. Furthermore, there isn’t an unbranded version of the shingles vaccine, which means that the commercially available vaccines are often part of the more expensive Tier 3 and 4 formularies in Part D plans.

    You’ll generally get your Shingrix vaccine for free if your state covers it and you’re a Medicaid beneficiary or you have a private plan covered by the ACA. However, many people end up paying for their Shingrix vaccine out-of-pocket because they haven’t paid their deductible if they have Medicare Part D or can’t find a suitable facility in their insurer’s network.

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