Tuesday, June 6, 2023

Does Medicaid Pay For Shingles Vaccine

How Does Medicare Cover The Shingles Vaccine

Medicare & You: Vaccines

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.

Is Shingrix Free For Seniors

The Shingrix vaccine isn’t automatically free for seniors. However, many seniors will have private health care insurance that covers Shingrix. According to the Shingrix website, the vaccine is included in 90% of private health care plans, with average costs of less than $5 per shot. You may also be eligible for a free Shingrix vaccine if you have Medicare Part D insurance.

The Affordable Care Act requires that most private health care insurance plans must cover preventative health care, including vaccines, without cost-sharing. This means that many insurers aren’t allowed to charge beneficiaries for vaccines like Shingrix. However, most providers require you to have your vaccine at an in-network facility to get your vaccine free.

How Effective Is The Shingles Vaccination

The Food and Drug Administration has only approved two shingles vaccines: Zoster vaccine live and recombinant zoster vaccine . To stop shingles, each performs a slightly different role.


Shingrix received FDA approval in 2017. It is the CDC-recommended vaccine for shingles protection, according to Trusted Source. Since the vaccine includes inactivated viruses, it is more endurable for those with weakened immune systems.


The Food and Drug Administration approved Zostavax in 2006 for the prevention of shingles and postherpetic neuralgia. A similar kind of live vaccine is the measles, mumps, and rubella vaccine.

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What Everyone Should Know About The Shingles Vaccine

Shingles vaccination is the only way to protect against shingles and postherpetic neuralgia , the most common complication from shingles. CDC recommends that healthy adults 50 years and older get two doses of the shingles vaccine called Shingrix , separated by 2 to 6 months, to prevent shingles and the complications from the disease. Your doctor or pharmacist can give you Shingrix as a shot in your upper arm.

Shingrix provides strong protection against shingles and PHN. Two doses of Shingrix is more than 90% effective at preventing shingles and PHN. Protection stays above 85% for at least the first four years after you get vaccinated.

Does Medicare Cover The Shingles Vaccine Will I Have To Pay For The Shot

Vaccine Guide

The CDC recommends people 50 years and older get the shingles vaccine. The shot is widely available and the cost may be covered if you have Medicare Advantage or Medicare Part D. Depending on your plan, you may have to cover a deductible, co-pay, or pay for the shot out of pocket and get reimbursement.

Shingles can cause serious complications, like painful long-term nerve damage. To stay safe from such complications, you may want to consider the new shingles vaccine . An older vaccine once widely administered in the U.S. was less effective and is no longer on the market.

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Pharmacy Administration Of Vaccines

Health First Colorado members may receive the following vaccinations by an enrolled pharmacist at a Health First Colorado-enrolled pharmacy:


To submit vaccine claims, please use these guidelines:

  • The pharmacy’s NPI is the billing provider
  • The pharmacist’s NPI is the rendering provider
  • A product code, as well as an administration code, must always be included in any claims for vaccination.

For additional information related to provider registration or claim submission, please visit the Quick Guides and Webinars web page.

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.

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Vaccine Administration Codes And Reimbursement Rates

The following codes should be used for all vaccine administration, including VFC vaccine administration for members 18 years old and younger. Report these codes in addition to the vaccine and toxoid code.

Please always refer to the fee schedule in the Provider Services section of the Department’s website for the most up-to-date rate information.

How Does Your Medicare Deductible Affect Your Vaccine Costs

Shingles Vaccine Update

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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The Incredible Importance Of Vaccines For Seniors

There is a lot of talk surrounding vaccines these days, especially surrounding the ongoing COVID-19 pandemic. However, its important to remember that other immunizations are just as important as well, especially for seniors.

As we age, our immune systems can get naturally weaker, and we may become more susceptible to serious diseases like shingles, pneumonia, the flu, tetanus, diphtheria, hepatitis, meningitis, and more. For this reason, the CDC has outlined a vaccine schedule for older individuals who are considered to be at higher risk of contracting viral infections.

Immunization is currently the best method we have for defending ourselves against serious viruses, and thats why important vaccines, like those for influenza , pneumococcal , and sometimes hepatitis B, are usually covered under Medicare Part B.

Do I Have To Pay For Vaccines With Medicare

You pay nothing for vaccines covered by Part B flu, pneumonia and Hepatitis B as long as your provider accepts Medicare.

Your cost for vaccines covered by Part D will depend on your specific plan. You may pay a copay or coinsurance, but it will depend on your plan and the provider.

The location where you get vaccinated may also affect your cost. For example, your costs may be lower if you get a vaccine at a pharmacy versus in a doctors office.

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Some Vaccines Covered Better Than Others

Unlike the flu and pneumonia vaccines, which are fully covered as preventive services under Medicare Part B, the shingles shot and other recommended vaccinations are covered as prescription drugs under Medicare Part D and Medicare Advantage plans.

Some of those plans provide better coverage than others, but nearly all of them divide their formularies, or list of covered drugs, into tiers according to cost. Drugs in Tier 1 and 2, mainly lower-priced generics and preferred brand-name drugs, have lower co-pays than more expensive nonpreferred brands in Tier 3 or 4.

Consumer Reports found that many Part D plans categorize the shingles vaccine, Zostavax, as an expensive Tier 3 or 4 drug. Only one pharmaceutical companyMerckmakes the shingles shot, and theres currently no generic version.

That means if you havent met your annual deductible, youll likely wind up paying full price for the shot, which is about $217. But depending on your plan, even after the deductible is met, consumers may have to pay a significant part of the shingles vaccine costup to $100.

Many healthcare providers havent set up billing systems to file claims through prescription drug plans. So if you’re vaccinated at your doctors office, you might be required to pay the full shingles vaccine cost up front and then file to be reimbursed by your insurance.

What Shingles Vaccines Are Available

Reducing Financial Barriers

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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Here are benefits we offer to help achieve that goal:

  • Large network of physicians, pediatricians and internists
  • Unlimited outpatient hospital services
  • Free over the counter medicine
  • Family planning services, including birth control and counseling
  • 24-hour Nurse Advice Line to answer medical questions

Additional Free Staywell Member Benefits:

  • Adult hearing and vision
  • Kids hearing and vision, plus well-child checkups
  • Doctor and hospital visits
  • Inpatient and outpatient hospital services
  • Emergency room services, Lab and radiology services
  • No-cost prescriptions
  • Behavioral health care and substance abuse treatment
  • Therapy services–occupational, physical, respiratory and speech
  • Podiatry services

Important Things to Remember When Getting Your Care:

  • We will pay for approved care
  • If you get a service that we do not approve, you may have to pay for it yourself
  • Sometimes we may not have a provider in our network who can give you needed care if this happens, we will cover the care out-of-network , but you will need to get approval first from us or your primary care provider
  • Some of these benefits require prior authorization. Find out how to get your services covered.

Doula Services for Pregnant MembersWe offer doula services to pregnant members. What is a doula? A doula is like a labor coach. He/She will work with you before, during and after you give birth.

Your doula will be there to:

MMA/LTC: Staywell Health Plans serves all areas in Florida except Broward County.

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.

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Guidance From The Department Of Health

NOTE: Effective August 1, 2020, all immunization records turned in to schools or child care centers are required by state law to be medically verified. Your child can’t attend until you provide these records.

Immunization records must be turned in to the school or child care on or before the first day of attendance. Records turned in to the school or child care must be from a health care provider, or you must attach paperwork from a health care provider to your handwritten form that shows your childs records are accurate. Your child can’t attend school or child care until you provide these records.

More information about the revised immunization requirement rules for school and child care can be found on the DOH School and Child Care Immunization webpage.

Childhood And Adult Immunization Scheduling

Shingles Vaccine Shortage Alarming Medical Officials

Washington Apple Health covers vaccines given according to the Advisory Committee on Immunization Practices immunization schedule for adults and children in the United States. View the Centers for Disease Control and Prevention childhood and adult immunization schedules.

Apple Health clients can get needed immunizations from:

  • Your health care provider.
  • Some pharmacies.
  • Some local health departments.

Ask your provider to schedule you for recommended immunizations to protect you and your loved ones from diseases that vaccines can prevent. Ask your provider for more information on the scheduling of your immunizations.

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What About Medicaid Vaccine Coverage For Children

Coverage is more substantial for children: Medicaid covers all recommended vaccines for enrollees younger than 21 years old, under the Early and Periodic Screening, Diagnostic, and Treatment benefit. The federally funded Vaccines for Children program also provides free vaccines for those who might otherwise skip vaccination because of an inability to pay. These coverage options are especially important because up through the age of 18, there are 13 separate vaccines the CDC recommends for most in that age group, many of which require more than one dose.

Does Medicare Cover The Shingles Vaccine

En español | Unlike some common vaccines, like those for the flu, hepatitis B and pneumonia, shingles shots are not covered under Medicare Part B, the component of original Medicare that includes doctor visits and outpatient services. Part A, which deals with hospital costs, doesnt cover shingles shots either.

Medicare coverage for Shingrix and Zostavax, the two commercially available shingles vaccines, is provided only if you are enrolled in a stand-alone Part D drug plan or a Medicare Advantage plan that includes Part D drug coverage.

Medicare requires Part D plans to cover the shingles vaccine, so if youre enrolled in Part D, you shouldnt have difficulty obtaining the shot. Most require a copayment, which can vary widely from plan to plan.

And if you havent yet met your plans deductible for the year, youll likely pay the full price. For Shingrix, the newer vaccine, that averages around $190, according to GoodRx, a website and app that tracks prescription prices.

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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 .

Who Needs The Shingles Vaccine

Reducing Financial Barriers

According to the Centers for Disease Control and Prevention , the Advisory Committee on Immunization Practices recommends the shingles vaccine for people 50 and older. It is a manufactured inactivated vaccine intended to prevent shingles. The vaccine is administered in two separate doses given by intramuscular injection, separated by two to six months.

The shingles vaccine is considered an important vaccine for seniors because our immune system weakens as we age. The recommendation for vaccination is based on the potential severity of symptoms and long-term complications.

A shingles vaccine called Zostavax is no longer used in the United States as of November 2020. If you received that vaccine, the CDC recommends talking with your doctor about getting the Shingrix vaccine.

The CDCs fact sheet on shingles lists these risks and potential complications:
  • About one in three people will develop shingles at some point in their lifetime.
  • More than 99% of people in the United States born before 1980 have had chickenpox , which poses risk for shingles.
  • Your risk for getting shingles and complications from it increase as you get older.
  • About one in 10 people who get shingles develop ongoing nerve pain.
  • Shingles may lead to other complications involving the eye, including blindness. Rarely, shingles may lead to pneumonia, hearing problems, brain inflammation, or death.

Shingrix is more than 90% effective at preventing shingles, but it does not prevent chickenpox.

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