Shingles is a contagious viral infection that causes a painful rash and blisters on the skin from a condition known as postherpetic neuralgia (post-hur-PET-ik noo-RAL-juh). It is caused by the varicella-zoster virus, which also causes chickenpox in young people. After having chickenpox, the virus doesn’t die, it lies inactive. When you are older, the virus sometimes reactivates as shingles.
Typically, the rash forms on the trunk of the body, wrapping around the flank area. The blisters last from 10 to 14 days on average and remain contagious until they’ve scabbed over. The pain from the rash can last well after the blisters have gone away.
The Centers for Disease Control and Prevention (CDC) reports that more than 99% of Americans 40 years old and older have had chickenpox. Fortunately, there are FDA-approved vaccines available now to help prevent chickenpox. So, what do you do if you’ve already had chickenpox but don’t want to get shingles?
You get a shingles vaccine!
The Shingles Vaccine
There are two widely available vaccines to help prevent shingles. Many doctors recommend that older patients receive the vaccine to prevent developing shingles (and avoid the pain!).
Zostavax is a live vaccine given in a single dose injection in the upper arm. It is recommended for patients 60 and older and is said to protect against the virus for up to five years.
Shingrix, which is given in two injections, is said to protect against shingles for over five years. This vaccine is recommended to patients 70 or older.
A quick web search shows that the average out-of-pocket costOut-of-pocket costs (aka, out-of-pocket medical expenses) are costs that a beneficiary must pay because their health insurance does not cover them. Out-of-pocket costs are found in the deductibles, copayments, and coinsurance outlined in each health... for either of these vaccines is between $185.00 and $200.00. So, let’s look at your Medicare plans to see if your coverage will cover the cost of the vaccine for you.
Does Medicare Cover the Shingles Vaccine?
Yes, Medicare covers the shingles vaccine. But it isn’t covered by Medicare Part A (hospital insurance) or Medicare Part B (medical insurance), often referred to as Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage...., it’s covered through Part D prescription drug coverage. If your Medicare Advantage plan includes Part DMedicare Part D is Medicare's prescription drug plan program. Plans are offered by private insurance companies and cover outpatient prescriptions.... benefits you can get it that way, too.
Across the board, all Medicare prescription drug plans (Part D) cover commercially available vaccines, including the most widely used shingles shots, Zostavax and Shingrix. However, the cost of coverage will vary. All Medicare Part D plans have copayments and nearly all have an annual deductibleA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share.....
How Much Does a Shingles Shot Cost with Medicare?
The price for Shingrix can range from $190 to $260. If you have a Medicare Part D plan for your prescriptions, but you have not yet met your annual deductible, you could end up paying the full retail price. It does not really matter if you get it at Walgreens, CVS, Rite Aid, or Walmart, because the rules for your Part D plan require you to pay the deductible before cost-sharing begins. The current price for Zostavax is similar at about $200.
Both Zostavax and Shingrix are name-brand drugs, so they are not available in tier 1, which generally covers generic prescription medications. Most plans cover these shots in tier 2 and a few bump them up to tier 3 in their formulary. So, if you have paid your Part D deductible in full for the year, look at your tier 2 copayments and you’ll have a good idea of your cost.
TIP: If you have a Part D drug plan, but you are unlikely to meet your deductible from regular prescriptions, you can look for discount coupons on GoodRx and SingleCare so you don’t have to pay full price.
Does My Medicare Supplement Cover the Shingles Vaccine?
No. Medicare supplement plans (MedigapMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage....) only cover the gaps in your Part AMedicare Part A is hospital inpatient coverage for people with Original Medicare, whereas Part B is medical coverage for doctor visits, tests, etc.... and Part B health insurance, which does not include vaccinations.
How Do I Get the Shingles Vaccine?
The shingles vaccine can be obtained two ways; at your primary care physician’s office, or at your pharmacy.
At Your Primary Care Physician’s Office
Before you go, ask your doctor’s office if you can receive the vaccine without a copay charge from the doctor. Most private insurance through Medicare AdvantageMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B).... will allow this, but an office visit on Original Medicare will charge you for both the visit and the vaccine, likely costing you hundreds of dollars. If you check beforehand, it won’t be a surprise when Medicare denies your claim for reimbursement.
At Your Pharmacy
Most major pharmacy chains, and some smaller, independent pharmacies, are also able to administer the Zostavax or Shingrix vaccine. If you have Part D, this is where you’ll go.
You will still need a prescription from your doctor and you’ll need to ensure that the pharmacy you choose is in your network. That way they can bill your plan and you’ll only be paying your copaymentA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service..... Don’t forget, with Medicare Part D coverage you must pay your annual deductible before the plan starts paying its share.
Free Shingles Vaccine for Seniors
If you qualify for both Medicare and Medicaid (dual-eligible, call your local Medicaid office about coverage for the shingles vaccine, which may be free or offered at a low cost. Rules are different in every state. If you are enrolled in the Social Security Administration’s Extra Help program, your cost will be minimal. The same is true if you have a Medicare Advantage SNP-D plan for dual-eligible people.
It Pays to Be Protected
There you have it. Does Medicare cover the shingles vaccine?
Yes. Through Medicare Part C and Part D health insurance plans, you can get the shingles vaccine shot. Just don’t expect your insurance company to offer it for free. At a minimum, you will have a copayment or coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. ....
Although Medicare Part D is optional, if you don’t sign up for it when you are first eligible and decide to sign up later, you could pay extra.
Getting coverage for common vaccines, like shingles, makes it worth it even if you don’t take prescriptions.
Citations
cdc.gov
- Shingrix Shingles Vaccination: What Everyone Should Know | CDC
https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html - Shingles Zostavax Vaccination | What You Should Know | CDC
https://www.cdc.gov/vaccines/vpd/shingles/public/zostavax/index.html - Shingles | About | Herpes Zoster | CDC
https://www.cdc.gov/shingles/about/index.html
medicare.gov
- Shingles Shot Coverage
https://www.medicare.gov/coverage/shingles-shots - Medicare.gov: the official U.S. government site for Medicare | Medicare
https://www.medicare.gov/ - Medicare.gov: the official U.S. government site for Medicare | Medicare
http://www.medicare.gov/
cms.gov
- https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNP…
- https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS10106.pdf
- 2020 Medicare Parts A & B PremiumsA premium is an amount that an insurance policyholder must pay for coverage. Premiums are typically paid on a monthly basis. In the federal Medicare program, there are four different types of premiums. ... and Deductibles | CMS
https://www.cms.gov/newsroom/fact-sheets/2020-medicare-parts-b-premiums-and-d…
goodrx.com
- Prescription Prices, Coupons & Pharmacy Information – GoodRx
https://www.goodrx.com/ - Shingrix Medicare Coverage and Co-Pay Details – GoodRx
https://www.goodrx.com/shingrix/medicare-coverage - Shingrix Prices, Coupons & Savings Tips – GoodRx
https://www.goodrx.com/shingrix