Does medicare cover the shingles vaccine?
The shingles vaccine shot is covered by Medicare prescription drug plans: Medicare Part D or Medicare Advantage Plan. If you do not have prescription drug coverage, you can enroll in Medicare Part D or Medicare Advantage Plan between January 1 – March 31, 2020. Furthermore, if you are in a Medicare Advantage Plan without drug coverage, you can switch to a Medicare Advantage Plan with drug coverage. On the other hand, you can drop Medicare Advantage Plan and join a Medicare prescription drug plan (Part D).
Medicare Part B covers the following FREE shots: flu shots, hepatitis B shots, and pneumococcal shots. However, Medicare Part B does not cover shingle shots. Likewise, Medicare Part A which covers inpatient hospital care also does not cover shingle shots. To get Medicare coverage for shingles vaccine shots you need to have either Medicare Part D or Medicare Advantage Plan with drug coverage.
It’s a good thing you can get Medicare coverage for shingles because an estimated 1 million people get shingles each year in the United States. In fact, the Centers of Disease Control and Prevention (CDC) reports about 1 out of 3 people in the United States will develop shingles in their lifetime. The shingles virus is called Herpes Zoster. If you have ever had chickenpox, you can get shingles. Most important for seniors the risk of developing shingles increases with age. Therefore, if you are age 65 or older, you have an increase risk of developing shingles. For this reason, many doctors recommend people on Medicare get shingle vaccine shots.
Why You Need Shingles Vaccine Shots
Shingles is a viral infection that affects the nerves. The shingles also called Herpes Zoster produces a painful rash with blisters as shown in the photo. When you get shingles vaccination shots, it helps reduce the risk of having shingles. In addition, the shingles vaccine can lessen the length and severity of illness if you get shingles.
People usually recover from shingles within weeks. However, in rare cases Shingles can have serious complications including death. In other cases, people experience Postherpetic Neuralgia and continue to have pain in the area where the rash had been for months or years after the skin has healed.
Shingles mostly affects older adults who had chickenpox when they were younger. If you are a senior age 65 or older, you have an increase risk of developing Shingles. The painful, blistering rash can cover many areas of your body including: waist, chest, stomach, buttocks, neck, or face. To prevent shingles you need to get shingles vaccine shots. You can either get Zostavax shot (zoster vaccine live) or Shingrix shot (zoster vaccine recombinant). At CDC advisory meeting on June 21, 2017 a study showed Shigrix significantly reduced the risk of developing shingles by 90 to 97% in subjects 50 years and older. By contrast, Zostavax cuts the risk of shingles by only 69.8% in those 50 to 59 years old, and by only 51% for people 60 years and older.
Choosing Your Shingles Shots
The Zostavax vaccine shot is subcutaneous, under your skin, and a one-time injection. The Shingrix shingles shot is intramuscular, in your muscle, and requires 2 injections. The second does is given 2 to 6 months after the first. Since Shingrix shot is into your muscle you can expect it to be more painful. However, it is more effective at reducing risk of shingles in seniors age 50 or older. Moreover, doctors recommend Shingrix for immunocompromised people because it is a recombinant, non-live vaccine.
Where and how to get shingles vaccine?
You can get the shingles vaccine at a pharmacy in your network. In other words, you want to make sure you get the Shingles vaccine in a pharmacy that is in your plan’s network. For seniors who want the most effective shingles vaccine, you can find a pharmacy or doctor near you for a Shingrix shot.
If your doctor vaccinates you, make sure the office staff bills your Part D or Medicare Advantage plan. Likewise, have your in-network pharmacy bill your prescription drug plan. Missing this step could result in you paying the entire bill and having to submit a reimbursement request to your plan.
What Does Shingles Vaccine Cost?
Before Medicare Part D or Medicare Advantage plan will pay anything, you must first pay the annual deductible. The shingles vaccine is a tier 3 drug with a higher deductible. In 2020, the average tier 3 annual deductible for Medicare Part D and Medicare Advantage is $435.
2019 Medicare Part D drug plan costs for Shingrix vaccine was about $50 per shot after you pay the deductible. Shingrix vaccination requires two shots. Therefore, your total out-of-pocket in-network costs is about $100. Shingrix retail drug cost is about $150 per shot. Medicare Part D drug plan will save you about $200 on two Shingrix vaccine shots.
2019 Medicare Part D drug plan costs for Zostavax vaccine was about $50 per shot after you pay the deductible. Zostavax vaccination only requires one shot. Therefore, your total out-of-pocket in-network costs is about $50. Zostavax retail drug cost is about $220 per shot. As a result, Part D drug plan will save you about $170 for the Zostavax vaccine shot.
As mentioned above, make sure the pharmacy or doctor’s office bills your Medicare Part D or Medicare Advantage plan.
Other Medicare Vaccine Coverage
Common Medicare Questions about Shingles Vaccine
Original Medicare does not cover shingles vaccine. However, Medicare Part D and Medicare Advantage plans with drug coverage do cover shingles vaccine.
Seniors or anyone 50 years or older should get the new Shingrix vaccine. This Shingrix vaccine is the best way to protect yourself against shingles according to the CDC. The Shingrix vaccine is covered by Medicare Part D and Medicare Advantage plan with drug coverage.
Shingrix is more than 90% effective at preventing shingles and long-term nerve pain. Shingrix vaccine is covered by Medicare Advantage with drug coverage and Medicare Part D.
About 1 out of 3 people in the United States will develop shingles during their lifetime. It is most common with people 50 years and older. Therefore, seniors are eligible for Medicare Part D and Medicare Advantage plans can get coverage for shingles vaccine.
Anyone who has had chickenpox can get shingles. More than 99% of Americans born before 1980 have had chickenpox, even if they do not remember it.
Your risk of shingles and complications increase as you age. Seniors age 65 and older are eligible for Medicare Part D and Medicare Advantage plans with drug coverage for shingles vaccine.
Shingle vaccines are approved for adults age 50 and older for the prevention of shingles and related complications (Mayoclinic.org).