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Does Medicare Part D Cover Shingrix

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Where Can I Get Vaccines I Need

Medicare Vaccinations for Medical Coders

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.

Medicare May Not Provide Good Coverage For This Vital Protection

If you’re covered by Medicare, you may feel the pain of a shingles shot more in your wallet than in your arm.

That’s because the federal program that insures most seniors in the U.S. provides poor coverage for some recommended vaccines, including shingles, and could leave some people paying $200 or more for protection.

Shingles is a viral infection that often causes a painful, blistering rash and, in some cases, leads to lingering nerve pain and, in rare cases, even blindness.

The vaccine isn’t foolproof, but for people aged 60 and older it reduces the risk of getting shingles by about 51 percent and, if you do get shingles, reduces the nerve pain it causes by close to 70 percent, according to the Centers for Disease Control and Prevention.

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.

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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

Shingles Vaccination Covered Under Medicare Part D

Can the co

Date Issued: 7/18/2012 Last Reviewed 4/6/2021

The shingles vaccination is excluded from medical benefits and covered under Medicare Part D for Medicare members. It is not covered under Medicare Part B. The shingles vaccination will only be covered if the member has a Medicare Part D Prescription Drug Plan.

The shingles vaccination is included in medical benefits and is covered for members over age 60 with GHI, HIP and EmblemHealth commercial products.

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider’s office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.

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How Does Medicare Cover The Shingles Vaccine

Original Medicare, Part A and Part B, does not cover the shingles vaccination but Medicare Part D does. To get this covered, you must enroll in either a stand-alone Medicare prescription drug plan or a Medicare Advantage plan that includes prescription drug coverage . You may have a copayment for the shingles vaccine.

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, orlearn more about Part D first.

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Which Vaccines Does Medicare Cover

Medicare covers a variety of vaccines. While Medicare Part B is generally known to cover most vaccines, Part D typically covers any vaccines that a Part B plan doesnt. Heres a table to help clarify which vaccines are covered by each plan:

Medicare Part B
Vaccines related to treating an injury or exposure to a diseaseAll other commercially available vaccines not covered by Medicare Part B

To learn whether or not your Medicare plan covers the vaccine you need, you should check your plans formulary. A formulary is a list of all the prescription drugs that your plan covers and how much they might cost you. Call your insurance company or insurance agency to learn more about your particular plans formulary.

Does Medicare Cover The Shingles Vaccine Conclusion

Best Medicare Supplement Plans / New

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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Why Is The Shingles Vaccine So Expensive

It is important to remember that bringing vaccines to market can cost $1 billion and take decades to develop, Amesh Adalja, MD, a board-certified infectious disease physician and senior scholar at the John Hopkins Center for Health Security. The burden of shingles and its after-effects are sizable, so it is important that the few companies that manufacture the vaccine have market incentives to continue to make vaccines. The demand for Shingrix is very high, with shortages occurring, so the price has not been a barrier to its uptake.

Enrolling in a program that covers shingles vaccines is the best way to save money. Medicare parts A or B do not cover shingles vaccines, but Medicare Part D plans do. The amount of coverage, copay, and deductibles that someone will have to pay as part of a Medicare Part D plan varies. Without health insurance, many people might not be able to afford their shingles vaccines.

Special Drug Coverage Rules

Some drugs have special coverage rules that may:

  • Limit the amount of a particular drug you can get
  • Require that you get prior approval from the plan before a drug is covered
  • Require that you first try a certain drug to treat your condition before another drug is covered
  • Limit which pharmacies you can use

Drugs that are subject to these rules are clearly marked in the formulary.

View the list of prescription drugs that currently have prior authorization or step therapy requirements and the rules that apply to each drug:

Saver plan

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How Much Does The Shingles Vaccine Cost

There are several vaccines covered by Medicare Part D, including shingles vaccines. Remember, your Medicare Part B does not cover the shingles vaccine.

However, you can find Zostavax and Shingrix on your Part D plan formulary. Check your Part D drug formulary to see which tier the vaccine falls into. Many plans put the vaccine into a Tier 3 category.

According to GoodRx, Shingrix retails for around $155 per shot. You need two rounds of the shot when getting this shingles vaccine. Zostavax is slightly more expensive, retailing for anywhere between $212 and $240 per shot.

If you receive your vaccine before you have met your Part D plans deductible, you will be responsible for 100% of the cost. However, if you get your vaccine after having met your deductible, you will simply pay a copay or coinsurance for the shot.

If you do not have a Part D drug plan, check pricing on GoodRx.com, where you can find coupons that may save you some money on this vaccine.

What Are The Costs For Medicare Part D Vaccines

What You Should Know About the Shingrix Vaccine for ...

The fact that a vaccine is covered by Medicare Part D does not necessarily mean you pay nothing for this vaccine. What you pay for a Medicare Part D vaccine depends on:

  • The type of vaccine
  • Where you get the vaccine
  • Who gives you the vaccine

In some cases, you may have to pay the entire cost for the vaccine medication and the administration of the vaccine and ask your Medicare Part D plan to pay you back for a share of the cost.

Do you have more questions about Medicare Part D coverage of vaccines? Feel free to enter your zip code on this page to browse Medicare plan options in your location. Or, if you prefer to get personalized assistance, contact us to speak with a licensed insurance agent. We can help you find Medicare plan options that address your Medicare needs.

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What Is The Cost Of The Shingles Vaccine With Medicare Part D

Since every insurance plan is different, each Part D plan provides varying degrees of coverage for the shingles vaccine. Some plans may place the vaccine in Tier 1 while others may put it under Tier 3 . Some plans may also have a deductible, meaning 100% of your vaccination or drug costs are on you until you meet the dollar amount specified by your insurance plan.

The best way to know how much a shingles vaccine may cost you is to call your insurance provider and ask.

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 will depend 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 other medications.

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How Much Does The Shingles Vaccine Cost With Medicare

Most people who are enrolled in Medicare Part D pay less than $50 per dose for Shingrix, according to the vaccine’s manufacturer GlaxoSmithKline. However, your costs will vary based on the plan’s details and if you’ve already met your deductible amount by purchasing other prescription drugs.

For example, some seniors can get the shingles vaccine for free because it’s fully covered by their Medicare Part D or Medicare Advantage plan. Others may have to pay a portion of the cost, such as a $50 copay per shot, or pay full price if the deductible hasn’t been met.

If you don’t have a prescription drug plan or you haven’t met your plan’s deductible, the retail cost for the shingles vaccine is $162 per shot in 2021. For the two-dose sequence, the total cost is $324. If the full price of the shingles vaccine is out of your budget, there are several ways you can save money on the vaccine.

How Does Your Medicare Deductible Affect Your Vaccine Costs

How to Access Data from CDCs VAERS WONDER System

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. Let’s compare how much you’d pay for the shingles vaccine on two plans with different deductibles.

Scenario: Shingrix is the only medication needed during the policy

AARP MedicareRx Walgreens
Cost of two doses of Shingrix vaccine$160 each for a total of $320 because the deductible hasn’t been met$45 copay each for a total of $90
Total annual cost of premiums and shingles vaccine$788 $1,122

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. 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.

In this situation, the person with the MedicareRx Walgreens plan pays less overall, even though they’re paying full price for the shingles vaccine.

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Whats Shingrix Zostavax And Shingles

FDA approved in 2017, Shingrix is the leading preventive tool against shingles . Shingles is caused by a once dormant chickenpox virus rearing its ugly head to give you a painful rash that can last for up to four weeks. For some, long-term pain continues even after the rash is gone, a condition known as postherpetic neuralgia.

Since 99% of people in the US have chicken pox by age 40, and since the risk of shingles increases with age, the Centers for Disease Control recommends that every healthy adult over 50 get Shingrix.1 Shingrix is over 90% effective at preventing shingles and postherpetic neuralgia, making it the preferred shingles shot.2 But for those who may be allergic to Shingrix, another shingles vaccine, Zostavax, can be used.

Zostavax may also be covered by Medicare prescription drug insurance , but again, you should check to be sure.

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About Insuring Your Health

KHN contributing columnist Michelle Andrews writes the series Insuring Your Health, which explores health care coverage and costs.

To contact Michelle with a question or comment, .

Many readers have contacted me about health insurance and the Affordable Care Act. Here are answers to some of their questions.

Q. I have Medicare and a Plan F Medigap plan, so I should be covered for all medical needs. But in order to get the shingles vaccination, it will cost me $185. I cant pay this without using my grocery or prescription money. Its totally unfair. What can I do?

A. Shingles is a painful rash caused by a virus that can lead to long-term nerve damage called postherpetic neuralgia. All Medicare Part D prescription drug plans cover the shingles vaccine, which is recommended by the Centers for Disease Control and Prevention for people age 60 and older. But Medigap plans, which may cover the deductible and coinsurance amounts for services provided under Medicare Parts A and B , dont offer any financial help on the co-payments for vaccines and other drugs covered under Part D.

A Government Accountability Office report published in December found that seniors faced many obstacles to getting needed vaccines, including the shingles vaccine. Many physicians dont recommend or even stock the shingles vaccine, the report found. The amount that the patient pays out of pocket for that vaccine could also be a barrier, according to the report.

Does Medicare Cover Shingrix Or Zostavax

Shingle Vaccine Cost

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.

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