Monday, May 16, 2022

Is Shingles Shot Covered Under Medicare

Don't Miss

What Are The Side Effects Of Shingrix

Medicare & You: Vaccines

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.

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.

Is The Shingles Shot Covered By Medicare

Original Medicare does not pay for the shingles vaccine. However, if youre enrolled in a Medicare prescription drug plan or have a Medicare Advantage plan that includes drug coverage, your shot may be covered. For vaccines covered under Part D , it is not recommended to get the shot through your providers office, as you may have issues with Part D billing.*

You May Like: When Can I Start Collecting Medicare Benefits

Does Medicare Cover The Shingles Vaccine

En español | Unlike some common vaccines, like those for the flu, hepatitis B and pneumonia, shingles shots are not covered under Medicare Part B, the component of original Medicare that includes doctor visits and outpatient services. Part A, which deals with hospital costs, doesnt cover shingles shots either.

Medicare coverage for Shingrix and Zostavax, the two commercially available shingles vaccines, is provided only if you are enrolled in a stand-alone Part D drug plan or a Medicare Advantage plan that includes Part D drug coverage.

Medicare requires Part D plans to cover the shingles vaccine, so if youre enrolled in Part D, you shouldnt have difficulty obtaining the shot. Most require a copayment, which can vary widely from plan to plan.

And if you havent yet met your plans deductible for the year, youll likely pay the full price. For Shingrix, the newer vaccine, that averages around $190, according to GoodRx, a website and app that tracks prescription prices.

More From This Series Insuring Your Health

Medicare

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.

Also Check: How To Sign Up For Medicare Part B Online

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.

There Are Two Approaches To Get A Medicare Shingles Vaccine

  • At the pharmacy. Youll require a doctors prescription, so after its been transmitted, youll be able to buy the injection at a retail pharmacy. The vaccine is available at most large chains and some small pharmacies. Use a pharmacy in your Part D plans network, and the pharmacy will bill the plan directly, leaving you with the applicable deductible and copayment.
  • In the doctors office. If you get vaccinated at a doctors office, find out if the office can charge your drug prescription plan directly or if it partners through a pharmacy that can. In the event that this is often the circumstance, itll work as already portrayed, with you owing a copayment. If not, you will be required to pay the entire amount upfront, and then make an application for compensation from the insurance company. Keep in mind if the doctors bill for prescribing the vaccination can surpass the plans permissible payment, in which case you will be responsible for the difference. Its still a smart idea to double-check all ahead of time.

Also Check: When Does One Qualify For Medicare

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.

Is It Cheaper To Get A Vaccine At My Doctors Office Or A Pharmacy

Shingles vaccine is recommended for healthy older adults

You may feel more comfortable getting shots at your healthcare providers office. Your provider knows your patient history and can provide a one-on-one experience. If you choose to get vaccinated at your providers office, keep in mind you may be billed for an office visit in addition to the cost of the shot.

For the COVID-19 vaccine, your provider shouldnt charge you if the vaccine was the only service you received. You should ask for a refund if you believe you were billed in error for the COVID-19 vaccine.

You can also get immunizations against flu, pneumonia, shingles, and other conditions at your local pharmacy. Youll be responsible for any copays or deductibles depending on your prescription drug plan, but you wont have an office visit copay.

Plus, your vaccine record will be kept on file as part of your permanent pharmacy history. When you get vaccinated at your pharmacy, your information is entered into the state immunization registry, which can be accessed by your doctor, Dr. Schaffner says.

You May Like: How To File A Medicare Claim Electronically

Vaccine Coverage Through Medicare Part D

Generally, Medicare prescription drug coverage covers all commercially available vaccines needed to prevent illness. To be safe, you should always check with your plans Member Services team first if youre thinking about getting a specific vaccine.

You can get Part D coverage through a stand-alone prescription drug plan, or through a Medicare health plan like Medicare Advantage. If you dont have prescription drug coverage, you might have to pay full price for the other vaccines you need or want.

How Pneumococcal Vaccines Work

Streptococcus pneumoniae is a kind of bacteria that causes pneumococcal disease. Besides pneumonia, this bacteria may also cause other serious diseases that include meningitis and bacteremia, according to the National Foundation for Infectious Diseases. All of these diseases have been associated with high fatality rates, particularly in vulnerable populations. The bacteria can spread through respiratory droplets .

The CDC says that there are currently two vaccines that have been approved for use to help you develop an immunity to this bacteria:

  • Pneumococcal polysaccharide vaccination PPSV23: This vaccine is commonly suggested for adults over 65 or with certain risk factors.
  • Pneumococcal conjugate vaccination PCV13:This vaccine is recommended for adults who are over 65.

In some cases, the CDC recommends a second dose of PPSV23, but at least five years should elapse between doses. Also, both vaccines may be recommended for certain adults with risk factors for developing one of the diseases.

Read Also: When Must You File For Medicare

Medicare & Shingles Shot Or Shingrix

Being covered by Medicare has many advantages because it helps you reduce the costs of many supplies and, thus, save money.

However, does it cover the shingles shot? Read to find out.

What Is Shingles?

Shingles is an infection caused by the varicella-zoster virus. It affects the skin, causing a rash, and sometimes it leads to nerve pain. People who had chickenpox have a higher chance of developing shingles.

While the virus may reappear anytime in people of many ages, people over 50 are the most likely to be affected by it.

Shingles starts off as a pain and itching on a specific spot of the skin. After a few days, the rash becomes visible and it looks similar to chickenpox. An episode of shingles usually lasts about 2-4 weeks.

Even if shingles is not contagious, the virus can spread to someone who has not had chickenpox. The person doesnt contact shingles, but chickenpox. The virus can spread by making contact with the fluid from the blisters. Also, its good to know that chickenpox has a higher contagiousness than shingles.

Does Medicare Cover the Shingles Shot?

Sadly, the answer to this question is no, unless you have a prescription plan.

The shingles shot is not be covered by Medicare Part A or Part B. Unlike other vaccines, it can only be covered by Medicare prescription drug plans . Thus, you have to enroll in a Medicare Advantage plan or a stand-alone Part D drug plan to cover the costs.

Medicare Drug Plans And The Shingles Vaccine

Medicare

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.

Recommended Reading: What Do You Need To Sign Up For Medicare

What Happens When You Get The Vaccine

As mentioned above, there is one option for the shingles vaccine: Shingrix.

Shingrix, which contains no live virus, is a two-dose vaccine series given in the muscle of the upper arm. The second shot is given two to six months after the first. In clinical trials, it was effective in nearly 97% of adults in their 50s over 97% effective for people in their 60s and over 91% effective for those aged 70 and above. It remains at near 85% effectiveness in all four years following vaccination.18

Shingrix is recommended if youre age 50 or older and have no severe immune problems.19

Effectiveness does come with a cost: In studies, seven in 10 people experienced pain from the Shingrix vaccine, and nearly half have muscle pain or fatigue and some had headaches, shivering, fever and nausea.20 21The CDC suggests avoiding strenuous activities for two to three days after getting either Shingrix shot.

If have previously received Zostavax, you can consider getting Shingrix. The CDC says Shingrix was safe and immunogenic when given five years or later after Zostavax. The agency adds there is no data or theoretical concerns that Shingrix would be any less effective if given sooner. 21

Zostavax was discontinued in 2020 by Merck and is no longer available in the United States.

What Vaccines Are Covered By Medicare

The following chart shows how some common vaccines are covered by Medicare.

Vaccine
Coronavirus 2019– Part BYou pay nothing for the vaccine, whether you receive 2 shots or only a single dose.
Influenza-Part BYou pay nothing for 1 flu shot per flu season if your doctor accepts Medicare assignment.
Pneumococcal-Part BYou pay nothing for 2 shots if your doctor accepts Medicare assignment.
Hepatitis B-Part BYou pay nothing if youre at medium or high risk for Hepatitis B and your doctor accepts Medicare assignment.
-Medicare Advantage plans with drug coverage-Part DCoverage rules and costs vary by plan.
Tetanus-Medicare Advantage plans with drug coverage-Part DCoverage rules and costs vary by plan.

These are only a few of the most commonly recommended vaccines. Check with your doctor or health care provider if you have questions about a specific immunization or vaccine that is not listed here.

Medicare Part B also typically covers vaccines after youve potentially been exposed to a dangerous disease or virus. For example, your rabies shot may be covered by Medicare Part B if you are bitten by a dog.

Read Also: Does Medicare Pay Anything On Dental

How Can You Save On The Cost Of The Shingles Vaccine

These five tips can help you to pay less for a shingles vaccine.

  • Visit an in-network pharmacy with a prescription: If you have a prescription drug plan, you could pay less for your vaccine by having it administered at an in-network pharmacy. Getting the shot at a doctor’s office may lead to an additional doctor’s fee for administering the vaccine.
  • Sign up for Medicare Part D or improve your drug coverage: During open enrollment, you can select a prescription drug plan that covers Tier 3 drugs including Shingrix. Remember to consider the total policy costs for all of your prescriptions. Also, if you receive a low-income subsidy, Medicare Part D plans could be available for free.
  • Get a discount coupon for the shingles vaccine: Pharmaceutical retailers and networks may offer vaccine discounts. Usually, you’ll present the coupon or the drug discount card at the pharmacy to get the savings.
  • Use a state pharmaceutical assistance program: A state program may be available to help you reduce the cost of prescription drugs including the shingles vaccine.
  • Get assistance from the vaccine maker: GlaxoSmithKline offers the GSK Patient Assistance Program for those who meet certain criteria, and you may qualify if you earn less than $32,200.
  • How Much Of Medicare Covers The Shingles Vaccine

    What Does Medicare Actually Cover?

    The shingles vaccine is not provided by Medicare Part A or Medicare Part B . This also means that if you have a Medicare Supplement or a Medicare Advantage plan, , they will not cover it either. In general, Medicare Part D prescription drug programs cover all commonly available vaccines that are needed to avoid sickness. The two commonly produced shingles vaccinations, Shingrix and Zostavax are only provided by Medicare if you have a stand-alone Part D drug plan or a Medicare Advantage plan that includes Part D drug coverage.

    The shingles vaccination is required to be covered by Medicare Part D programs. Most entail a copayment, which varies greatly between plans. If you havent fulfilled your plans deductible for the year, youll almost certainly have to pay a majority of the amount.

    Read Also: How Do I Enroll In Medicare Part A And B

    Does Medicare Cover Pneumonia Shots

    Medicare Part B typically covers pneumonia shots, which help prevent certain types of pneumonia.

    Medicare Advantage plans also cover pneumonia shots. Many Medicare Advantage plans also cover prescription drugs and other benefits that Medicare Part A and Part B don’t cover.

    Medicare typically covers 100 percent of the Medicare-approved amount of your pneumococcal vaccine .

    Before getting your pneumonia shot, verify with your doctor that it is 100 percent covered by Medicare.

    The Centers for Disease Control and Prevention recommends PPSV23 pneumococcal vaccinations for all adults who are 65 years of age or older.

    There are currently two pneumococcal vaccines that have been approved for use for the prevention of pneumonia. Both vaccines are covered under Medicare Part B however, the order in which you receive them matters. Talk to your health care provider to learn more.

    More articles

    Popular Articles