Does Medicare Cover Shingrix And The Shingles Vaccine
By Kristen Roloff, quality care coordinator at Network Health Originally published on 10/27/2020 at 8:00 a.m.
As most of us age, we start to become familiar with the names of common medicines and immunizations to help keep us living our best and healthiest lives. One of these immunizations has been getting a lot of attention for its ability to prevent a serious health issue. Were talking about shingles and the vaccine to prevent it, called Shingrix.
Can I Get Shingles If Ive Had Chickenpox Already
Yes. After you have chickenpox, the virus stays in your body. It might go many decades before resurfacing or never come back at all. As you get older, the chance of the virus reappearing as shingles becomes more significant and can also lead to other negative health effects.
It is rare but possible to get shingles more than once.
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.
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Who Should Get Zostavax
People 60 years of age or older should get shingles vaccine . They should get the vaccine whether or not they recall having had chickenpox, which is caused by the same virus as shingles. Studies show that more than 99% of Americans aged 40 and older have had chickenpox, even if they dont remember getting the disease. There is no maximum age for getting shingles vaccine.
Two vaccines are licensed and recommended to prevent shingles in the U.S.. Zoster vaccine live has been in use since 2006. Recombinant zoster vaccine , has been in use since 2017 and is recommended by ACIP as the preferred shingles vaccine.
Even if you have had shingles, you can still receive shingles vaccine to help prevent future occurrences of the disease. There is no specific length of time you must wait after having shingles before receiving shingles vaccine, but generally you should make sure the shingles rash has disappeared before getting vaccinated. The decision on when to get vaccinated should be made with your healthcare provider.
Talk with your healthcare provider if you have questions about shingles vaccine. Shingles vaccine is available in doctors offices and pharmacies. To find doctors offices or pharmacies near you that offer the vaccine, visit Zostavax or HealthMap Vaccine Finder.
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.
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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.
Shingles Medicare Billing Problems
Heres a quick reminder about a billing issue that we commonly resolve for our clients. Many doctors continue to bill this to Medicare Part B, and then the bill gets rejected. Once the rejection happens, far too many Medicare beneficiaries just pay these bills without questioning them. One client remembered that our Client Service Team provides FREE help resolving bills like these and called us for support.
Her doctors office had tried to bill her $710 for this medication which is ridiculous! The shingles vaccine costs between $150 $300, and if your Part D plan is covering part of the cost, even less. So, please dont pay any medical bills that you receive without checking with us first.
Do you have questions about which Medicare plans will cover the shingles vaccine? Or perhaps you need help finding a drug plan that includes other vaccines covered by Medicare Part D? Give us a call.
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How Well Does Zostavax Work
Zostavax®, the shingles vaccine, reduced the risk of shingles by 51% and the risk of post-herpetic neuralgia by 67% based on a large study of more than 38,000 adults aged 60 years or older. Protection from shingles vaccine lasts about 5 years.
While the vaccine was most effective in people 60 through 69 years old, it also provides some protection for people 70 years old and older.
Adults vaccinated before age 60 years might not be protected later in life when the risk for shingles and its complications are greatest.
Does Medicare Cover Shingles Vaccines
Most health insurance companies cover shingles vaccines, and so does Medicare. However, Original Medicare coverage wont cover the vaccines. You must be enrolled in a Medicare Part D drug plan or a Medicare Advantage Plan that includes drug coverage in order to have prescription drug coverage that covers shingles vaccines. Medicare Part A or Medicare Part B , components of Original Medicare, wont cover shingles vaccines.
Other Medicare supplement plans, like Medigaps, dont cover shingles vaccines either.
You can enroll in a Medicare Part D prescription drug plan by itself, or enroll in a Medicare Advantage plan that includes Part A, B, and D coverage. Either of these options will usually cover the Shingrix vaccine.
Every Medicare Part D plan is different and copays or coinsurance may vary from plan to plan. Deductibles also may apply.
Different Medicare Part D plans classify medications and vaccinations into different tiers. What tier your plan puts shingles vaccinations into will determine your copay. The best way to determine the insurance plan thats best for you is to compare formularies to find the one that covers as many of your medications and vaccinations as possible or contact Medicare customer support.
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Fixing Medicare Vaccine Coverage Once And For All
Nonetheless, barriers to vaccine access remain for seniors due to the separate benefit part placement of vaccines in Part B and D. In seeming acknowledgment of the above problem, Congress acted rapidly to provide for coverage of COVID-19 vaccines without cost sharing under Part B when it passed the Coronavirus Aid, Relief, and Economic Security Act in March 2020, a full eight months before the first vaccine was authorized for emergency use.
As early as 2007 and as recent as 2021, the Medicare Payment and Access Commission recommended moving the coverage of vaccines from Part D to Part B. In the 2007 report, MedPAC foresaw the challenges stemming not only from beneficiary OOP costs under Part D, but also the challenges of physician out-of-network status under Part D. While pharmacists have long been permitted to roster bill vaccinations under Part B, easing the hurdle of split benefit part placement, physicians continue to face difficulty in offering Part D vaccines. Because they are out of network, this makes it difficult to ascertain coverage and cost sharing information. This may lead to patients paying the full cost of vaccines up front and seeking reimbursement under Part D later. This exacerbates the already burdensome financial requirements that result in lagging adult vaccine offerings in physician offices.
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S Of Medicare That Cover The Shingles Vaccine
The part of Medicare that covers the vaccine is your Medicare Part D plan or the Medicare prescription drug plan. Remember that a Part D plan is optional, so you might not be enrolled in one of these plans unless you decide to sign up for coverage. Part D typically provides coverage for prescription drugs, and the shingles vaccine is one drug that most plans cover. If you are enrolled in a Medicare Advantage plan, then your plan likely includes prescription drug coverage that will cover the vaccine. Since these Advantage plans are insurance plans administered by private insurance companies, you should contact your provider if you have any specific coverage questions or need help with the details of your plan. Many people also wonder if Medicare covers eye exams. These Medicare Advantage plans often include additional benefits like dental and vision coverage.
Original Medicare will not cover the shingles vaccine. Medicare Part A, or hospital insurance, pays for hospital stays and inpatient care. Vaccines and preventive services are never covered under Medicare Part A. Medicare Part B, which is more traditional medical insurance, pays for doctors office visits, outpatient care, and many preventive services. Part B will cover many immunizations, like the flu vaccine, pneumonia vaccine, and hepatitis B vaccine. Unfortunately, Part B does not cover the shingles vaccine. If you are not enrolled in a Part D plan, then this vaccine will be an out-of-pocket cost for you.
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S For Getting Coverage For The Shingles Vaccine
If you currently only have Original Medicare, how can you get coverage for the shingles vaccine? First, you will need to sign up for a Medicare Advantage Plan or a Medicare Part D prescription drug plan to get coverage for the shingles vaccine. You should thoroughly research the plans available in your area. Eligibility for Advantage plans is based partly on where you live, so not all plans are available in all areas. An independent insurance agent can also help you choose the best Medicare Advantage plan for your needs.
Once you find a plan that meets your needs, you should check the coverage details to make sure that the shingles vaccine is covered. More than likely, you will need to meet a deductible before the plan pays for treatment. If you have already met your deductible and paid for the vaccine out-of-pocket, then you might be eligible for reimbursement for some of the charges. If you have questions about Medicare coverage for the shingles vaccine, there are many resources available at Medicare.gov. You can also give them a call at 1-800-633-4227 or TTY at 1-877-486-2048.
Medicare And The Shingles Vaccine: Are You Covered
The shingles vaccine is covered through Medicare Part D or Medicare Advantage as part of your prescription drug benefits. In 2022, your actual costs for the vaccine depend on the specifics of your plan.
Beginning Jan. 1, 2023, all vaccines will be free under Medicare Advantage or Part D including shingles. No matter your plan, you’ll pay no deductible, copay or other costs for a shingles vaccine.
In 2022, you could pay less than $50 per shingles shot with a Medicare Part D plan from Aetna or Wellcare. If you don’t have prescription drug coverage, the full price for two doses of the Shingrix vaccine is $324, and several cost-saving options can help you get Shingrix for less.
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Where To Get The Shingles Vaccine
You have a few different options on where to get the shingles vaccine. You usually can receive it directly from your doctor at a doctors office or at a pharmacy.
The major pharmacy chains typically offer shingles shots so you should be able to get it at a location near you. You will still need a prescription from your doctor in order to get it at a pharmacy.
Who Can Administer Your Shingles Shot?
The vaccine is administered as a shot to your upper arm. While the Shingrix vaccine is safe and effective at preventing shingles, there are some possible side effects. According to the CDC, you may experience some common mild symptoms associated with vaccines, such as arm soreness, muscle pain or a headache.
Remember that the vaccine comes in two doses, so you will have to return to wherever you got the shot two to six months later to receive the second dose. The immune reaction may come with the first or second dose, or with both doses of Shingrix.
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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.
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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Do I Need A Prescription For A Shingles Vaccine
Once you have a Medicare insurance plan that covers the shingles vaccine, youll need to find out whether a prescription is necessary. This is dependent on where you get vaccinated. You wont need a prescription if you get vaccinated at your doctors office.
Some pharmacies that provide vaccines do so under the standing order of a supervising physician. This is convenient for patients because it saves them a trip to the doctors office to acquire a prescription before receiving the vaccine. You may need to call your pharmacy to see how they handle shingles vaccine orders.
If your pharmacy requires a prescription, youll need to contact your medical provider first. They may want to see you in the office beforehand, but not always. Sometimes, the doctor may give you the shingles vaccine at your appointment.
Once you have the prescription in your possession, the remaining steps are pretty straightforward. Take the prescription to a pharmacy in your plans network to be filled. A pharmacist will administer the vaccine in their clinic area.
Its possible to save money on shingles vaccines with a SingleCare pharmacy savings card. SingleCare coupons can help uninsured or underinsured patients get shingles vaccines at a discounted price.
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Where To Get Vaccinated
You have a choice on where to get vaccinated.
In your doctors office: You can get vaccinated in your doctors office. If the office is set up to bill Part D directly for your vaccination, you may only have to pay a copay at the time of your shingles shot. If not, you may have to pay all costs upfront and submit a claim to your Part D plan for reimbursement.
At your local pharmacy: You can go to your local pharmacy to get your shingles shot as long as they offer the vaccine and appropriately trained staff members administer it. The rules for pharmacy vaccination vary by state. You will likely need to pay for the vaccination upfront. Pharmacies are not legally required to dispense medications without payment.
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What Shingles Vaccines Are Available
According to the Centers for Disease Control and Prevention , there are 2 vaccines licensed and recommended to prevent shingles in the U.S.: Shingrix and Zostavax.2 The CDC recommends that healthy adults 50 years and older get 2 doses of Shingrix, separated by 2 to 6 months, to prevent shingles and the complications from the disease.3
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Vaccines Covered By Medicare Part B
Medicare Part B covers three important vaccines as part of its preventive care benefits.
Covered vaccines include the following:
- Flu vaccine: Annual vaccine given in one shot before or during flu season, usually November through April
- Pneumonia vaccine: One-time vaccine given in two shots at least one year apart
- Hepatitis B vaccine: One-time vaccine given in two to four shots over one to six months for people who are medium to high risk, including people with diabetes
Part B also covers vaccines you may need if youre exposed to a harmful virus or bacteria by accident. You might need a tetanus shot, for example, if you step on a rusty nail. Or you may need rabies shots if youre bitten by a stray dog.
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