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.
Get Help With Medigap Coverage For Shingles
If you get shingles, you could have a long road to recovery and significant out of pocket expenses for doctor bills. A Medigap plan helps by paying the portion of your bill that Medicare doesnt pay.
At MedicareFAQ, we can answer all your questions about Medigap and help you find an affordable plan.
To get started, give us a call at the number above. Or, fill out our form
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Whats The Cost Of The Shingles Vaccine
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.
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What Are The Side Effects Of Shingrix
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.
Will Medicare Pay For Shingrix
You are going to want to make sure you have the correct Medicare plan .
BGA Insurance Group can help ensure that you are not surprised by charges you were not expecting. If you believe you need to get certain vaccines or prescription medications, you should contact us immediately to help you select a plan that makes the most sense for you.
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What Are The Possible Side Effects Of Shingrix
Studies show that Shingrix is safe. The vaccine helps your body create a strong defense against shingles. As a result, you are likely to have temporary side effects from getting the shots. The side effects may affect your ability to do normal daily activities for 2 to 3 days.
Most people got a sore arm with mild or moderate pain after getting Shingrix, and some also had redness and swelling where they got the shot. Some people felt tired, had muscle pain, a headache, shivering, fever, stomach pain, or nausea. About 1 out of 6 people who got Shingrix experienced side effects that prevented them from doing regular activities. Symptoms went away on their own in about 2 to 3 days. Side effects were more common in younger people.
You might have a reaction to the first or second dose of Shingrix, or both doses. If you experience side effects, you may choose to take over-the-counter pain medicine such as ibuprofen or acetaminophen.
If you experience side effects from Shingrix, you should report them to the Vaccine Adverse Event Reporting System . Your doctor might file this report, or you can do it yourself through the VAERS websiteexternal icon, or by calling 1-800-822-7967.
If you have any questions about side effects from Shingrix, talk with your doctor.
The shingles vaccine does not contain thimerosal .
Is There A Downside To The Shingles Vaccine
Though the vaccine is deemed safe by the U.S. Food and Drug Administration , there are certain conditions in which the vaccine may not be safe for you.
- The shingles vaccine has only been tested in adults over age 50 years and immunocompromised adults above 18 years thus, there is no recommendation for the vaccine for younger ages by the FDA.
- You should not get the vaccine if you have had a severe allergic reaction to a previous Shingrix dose.
- You have tested negative for immunity to varicella-zoster virus .
- You have an active shingles infection.
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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.
Getting The Shingles Vaccine
The Shingrix vaccine is produced by GlaxoSmithKline and approved by the Food and Drug Administration for the prevention of shingles in adults 50 and older. The vaccine is administered in two doses, with the second shot given two to six months after you receive the first shot.
The shot works by boosting your bodys defenses against shingles. In clinical trials, Shingrix was 90 percent effective in preventing shingles.
You can get the Shingrix vaccine at the doctors office or a retail pharmacy with a prescription. Its administered as an injection in the upper arm. After the shot, you may experience pain, redness, or swelling at the injection site as well as muscle pain, tiredness, or headaches.
You must get the second dose two to six months after the first shot. You can sign up for second-dose reminders through the Shingrix website to help keep you on track.
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Medicare Coverage For Shingles Vaccine
Shingrix is not the first shingles vaccine, but it is the only one currently on the market in the United States.Instead of using a live virus,the vaccine uses a protein from the virus to trigger an immune response. It is administered in two doses two to six months apart.
This shingles vaccine has been shown to decrease the risk for shingles by 97% for people between 50 and 69 years old and by 91% for people 70 and older. It reduces complications as well. The risk for post-herpetic neuralgia goes down by 91% and 89%, respectively, in those age groups.
Because the vaccine works well, it is important to know if and when Medicare covers it.
How Does Your Medicare Deductible Affect Your Vaccine Costs
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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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.
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.*
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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.
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.
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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.
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
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What Are My Options For The Shingles Shot
The two options for the shingles shot are Zostavax and Shingrix. Zostavax, according to the Mayo Clinic, protects against shingles for about five years. Its a live vaccine given as a single shot in the upper arm. The Zostavax shingles shot is recommended to adults age 60 and over which reduces the risk of developing shingles by 51%, according to the Centers for Disease Control and Prevention .
Studies suggest that Shingrix offers protection against shingles for more than five years. Its a nonliving vaccine given in two doses. The Shringrix shingles shot is recommended for adults age 50 and older.
The Shingrix shingles vaccine is more effective than Zostavax. Shingrix is more than 97% effective in preventing shingles in adults 50 to 69 years old after two doses. The Shingrix shingles vaccine is 91% effective in preventing shingles in adults age 70 and older, according to the CDC.
Why Is The Shingles Vaccine Not Covered By Medicare
Medicare Part B covers COVID-19, influenza and pneumococcal vaccines. It may also cover the Hepatitis B vaccine if your doctor thinks you are at a higher risk of contracting the disease. However, original Medicare doesn’t cover the shingles vaccine, and it’s unclear exactly why.
However, you may be covered for the shingles vaccine if you purchase Medicare Part D insurance through an approved private insurer or have a Medicare Advantage Plan that includes Part D coverage. However, you’ll be liable for your Part D deductible if you haven’t already paid it in the year you have your shingles vaccine. Part D deductibles vary widely between providers, but there is a mandatory maximum cap of $445 as of 2021.
The only commercially available shingles vaccines are Shingrix and Zostavax. The average cost of a Shingrix shot is around $190, so beneficiaries who haven’t yet paid their deductible are likely to end up paying for the entire cost of their shingles vaccine.
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Which Vaccines Does Medicare Cover
Medicare covers most vaccines. Some are covered by Part B, and some are covered by Part D.
Getting the vaccines you need is one of the most important things you can do for your health and for the health of those around you. Vaccines are your first line of defense against a number of infectious diseases. If you dont get sick, then you cant infect your loved ones, your friends or others in your community.
What Vaccines Are Covered By Medicare
The following chart shows how some common vaccines are covered by Medicare.
| Vaccine | ||
|---|---|---|
| Coronavirus 2019 | – Part B | You pay nothing for the vaccine, whether you receive 2 shots or only a single dose. |
| Influenza | -Part B | You pay nothing for 1 flu shot per flu season if your doctor accepts Medicare assignment. |
| Pneumococcal | -Part B | You pay nothing for 2 shots if your doctor accepts Medicare assignment. |
| Hepatitis B | -Part B | You 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 D | Coverage rules and costs vary by plan. | |
| Tetanus | -Medicare Advantage plans with drug coverage-Part D | Coverage 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.
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About The Shingles Vaccine
The Centers for Disease Control and Prevention recommends that healthy adults over the age of 50 get the shingles vaccine because it’s the only way to protect against the disease and its associated side effects. The risk of getting shingles increases as you age or if you have a weakened immune system. Always consult your doctor to find out if the shingles vaccine is right for you.
The CDC recommended vaccine, Shingrix, is a recombinant zoster vaccine that has two doses administered within six months of each other. It’s classified as a Tier 3 drug by most insurance companies, which means it’s a brand-name pharmaceutical with a higher copayment than a Tier 1 or 2 drug.
Use the Shingrix vaccine locator to find where the shingles vaccine is being offered, and check with your Medicare Part D or Medicare Advantage provider to see which locations give you the lowest price.
