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Does Medicare Cover the Shingles Vaccine?

December 14, 2023

Does Medicare Cover the Shingles Vaccine?

Yes, Medicare covers the shingles vaccine if you have prescription drug coverage (Part D). If you're wondering about the specifics, it's vital to understand that Medicare Part A and Part B don't currently include coverage for the shingles shot. 

 

Whether it's added to your Original Medicare or part of your Medicare Advantage plan, a prescription drug plan ensures coverage for the shingles vaccine. These plans, offered by private insurance companies, are designed to cover all commercially available vaccines for preventing illnesses, except for those already covered by Part B.
 

What are shingles?

 

Shingles (Herpes Zoster) is a painful and often itchy rash that tends to develop on one side of the face or body. Here's what you need to know:

 

  • Rash Description: The rash usually occurs in the formation of blisters, which commonly scab over within 7 to 10 days. The complete resolution of the rash typically occurs over a period of 2 to 4 weeks.
  • Early Symptoms: Before the rash appears, individuals may experience pain, itching, or tingling in the area where the rash is about to develop. This precursor discomfort can manifest several days before the rash becomes visible. Additionally, it's common for people to have a fever preceding the rash.
  • Usual Symptoms: The rash typically manifests as a distinctive pattern, forming single stripes on either the left or right side of the body or face, potentially affecting the eye and causing vision loss. While rare, the rash might be more widespread on the body, resembling a chickenpox rash, typical in individuals with weakened immune systems. 
  • Additional Symptoms: Shingles isn't just about the rash. Other symptoms may include:
    • Headache
    • Chills
    • Upset stomach

The go-to vaccine for preventing shingles and associated complications is the Recombinant Zoster Vaccine, commonly known as RZV or Shingrix.

  

Medicare Coverage for shingles vaccines

 

Medicare Part A and B

 

Original Medicare, that's Parts A and B, don't cover the shingles vaccine. So, if you want coverage for the shingles vaccine, you must sign up for a Medicare Part D plan. Part D deals with prescription drugs and covers vaccines like the one for shingles, as long as medically necessary. Just ensure to check your plan details to get a complete understanding of your coverage.

 

Medicare Advantage 

 

If you have Medicare Part D or Medicare Advantage plan with Part D prescription drug coverage, you're in luck—your shingles vaccination typically has coverage without requiring any out-of-pocket expenses. 

 

These plans, administered by private insurance companies approved by Medicare, are mandated to deliver at least the same level of coverage as Original Medicare (Parts A and B). Many Medicare Advantage plans sweeten the deal by offering additional benefits like prescription drugs, dental, vision coverage, and hearing benefits. Therefore, if your Medicare Advantage plan includes Part D, it's likely to cover the shingles vaccine as part of its preventive services, shielding you from the potential discomfort of shingles caused by the varicella-zoster virus. 

 

The following section will delve into the specifics of costs associated with this coverage.

 

How much does the shingles shot cost?

 

Under Medicare Part D, the cost of the shingles vaccine in 2023 has experienced a significant reduction thanks to the Inflation Reduction Act. As of this year, all out-of-pocket vaccines recommended by the CDC’s Advisory Committee on Immunization Practices, including the shingles vaccine, have been eliminated, regardless of whether you have drug coverage from Part D or a Medicare Advantage plan. 

 

This change marks a departure from the previous situation where copayments were commonplace. However, without prescription drug coverage, the Shingrix vaccine, approved by the Food and Drug Administration in 2017, could set you back more than $180 per dose. The manufacturer's list price, reported by GSK as of January 2023, is $366.82 for the vaccine or $183.41 per dose. It's important to note that out-of-pocket costs may vary based on your insurance status, plan, and the individual pharmacy's pricing, highlighting the importance of understanding your specific coverage.

 

Where can I get a shingles vaccine?


 

Getting a shingles shot is convenient, with most opting for pharmacies or doctor's offices. The rules around obtaining the shingles vaccine have evolved, with many states now allowing pharmacy access without a doctor's prescription. Pharmacists across all states are authorized to administer vaccines listed on the CDC-recommended adult immunization schedule, including the shingles vaccine. 

 

It's crucial to ensure your chosen pharmacy is part of your Medicare Part D plan's network, enabling them to bill your plan directly. Verify with both your pharmacy and insurance plan for specific details. If you prefer a doctor's office, ensure they can bill Medicare Part D directly to avoid potential upfront costs. If this isn't an option, you might have to pay for the vaccine initially and then seek reimbursement from your Part D plan. Clarifying these details with your doctor's office and insurance plan beforehand will help streamline the process and avoid unexpected expenses.


 

Sources

https://www.cdc.gov 

https://www.cms.gov

https://www.gskforyou.com

https://my.clevelandclinic.org



 

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