Why Is The Shingles Vaccine Not Covered By Medicare

My Spouse Had It Twice

Other Types Of Plans Do Better

Other forms of insurance do a far better job covering immunizations.

Under provisions of the Affordable Care Act, private planssuch as insurance through your employer or purchased on a state marketplaceare still required to cover recommended vaccinations as preventive medical care, not drugs.

That means that as long as you go to a provider in your plans network, your insurance will pay for preventive care without a co-pay, even if you havent met your deductible.

Its really a shame that older Americans, who are most at risk of contracting shingles and most vulnerable to the potentially serious effects of the disease, often have to pay more than others for the vaccine, says Consumer Reports medical director, Orly Avitzur, M.D.

If youre currently covered by a private health plan but anticipate going on Medicare in the next five years or so, one cost-saving strategy is to talk to your doctor about updating all your vaccinations now while your insurance provides good coverage, Avitzur says. The shingles shot is recommended for nearly all adults aged 60 and older.

When Should I See A Doctor Because Of The Side Effects I Experience From Shingrix

In clinical trials, Shingrix was not associated with serious adverse events. In fact, serious side effects from vaccines are extremely rare. For example, for every 1 million doses of a vaccine given, only one or two people may have a severe allergic reaction. Signs of an allergic reaction happen within minutes or hours after vaccination and include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, or weakness. If you experience these or any other life-threatening symptoms, see a doctor right away.

Shingrix causes a strong response in your immune system, so it may produce short-term side effects more intense than you are used to from other vaccines. These side effects can be uncomfortable, but they are expected and usually go away on their own in 2 or 3 days.

Read Also: Can I Get Tdap At Cvs

How Much Does The Shingles Vaccine Cost With Medicare

Most people who are enrolled in Medicare Part D pay less than $50 per dose for Shingrix, according to the vaccine’s manufacturer GlaxoSmithKline. However, your costs will vary based on the plan’s details and if you’ve already met your deductible amount by purchasing other prescription drugs.

For example, some seniors can get the shingles vaccine for free because it’s fully covered by their Medicare Part D or Medicare Advantage plan. Others may have to pay a portion of the cost, such as a $50 copay per shot, or pay full price if the deductible hasn’t been met.

If you don’t have a prescription drug plan or you haven’t met your plan’s deductible, the retail cost for the shingles vaccine is $162 per shot in 2021. For the two-dose sequence, the total cost is $324. If the full price of the shingles vaccine is out of your budget, there are several ways you can save money on the vaccine.

Whats Shingrix Zostavax And Shingles

FDA approved in 2017, Shingrix is the leading preventive tool against shingles . Shingles is caused by a once dormant chickenpox virus rearing its ugly head to give you a painful rash that can last for up to four weeks. For some, long-term pain continues even after the rash is gone, a condition known as postherpetic neuralgia.

Since 99% of people in the US have chicken pox by age 40, and since the risk of shingles increases with age, the Centers for Disease Control recommends that every healthy adult over 50 get Shingrix.1 Shingrix is over 90% effective at preventing shingles and postherpetic neuralgia, making it the preferred shingles shot.2 But for those who may be allergic to Shingrix, another shingles vaccine, Zostavax, can be used.

Zostavax may also be covered by Medicare prescription drug insurance , but again, you should check to be sure.

Read Also: Does Cvs Do Tetanus Shots

Is The Shingles Shot Covered By Medicare

Original Medicare does not pay for the shingles vaccine. However, if youre enrolled in a Medicare prescription drug plan or have a Medicare Advantage plan that includes drug coverage, your shot may be covered. For vaccines covered under Part D , it is not recommended to get the shot through your providers office, as you may have issues with Part D billing.*

Does Medicaid Cover The Shingles Vaccine

• Does Medicaid cover the shingles vaccine? Find out whether Medicaid covers shingles vaccines like Shingrex, including what you’ll pay and who’s eligible.

Shingles is a painful rash caused by a reactivation of the chickenpox vaccine. The condition can also cause complications such as postherpetic neuralgia, which causes long-term nerve pain. The Centers for Disease Control and Prevention recommends that people over 50 receive two shots of Shingrix, a vaccine that prevents shingles and associated complications. Many people want to know if Medicare covers the shingles vaccine. Below, you can find out everything you need to know about shingles vaccine coverage through Medicaid and Medicare.

You May Like: Does Cvs Give Tetanus Shots

Why Is This New Vaccine More Effective

Infectious disease specialist Dr. Lynora Saxinger says after reading preliminary papers on the Shingrix vaccine, she was very impressed.

“It genuinely is a big step up in vaccinating against varicella-zoster virus . It has much higher rates of protection that seems to not matter how old you are,” Saxinger tells The Current‘s Anna Maria Tremonti.

That is not the case with the older shingles vaccine Zostavax, she argues. While it is decent at reducing risk, it would depend on age on how well a patient would be protected. The vaccine does not respond well to an older immune system, says Dr. Saxinger, highlighting this as a real problem given the elderly are at a higher risk of contracting shingles.

“This actually kind of gives the 80-year-old the immune system of a 20-year-old,” says Dr. Saxinger.

“It seems to provide potentially long-lasting immunity, at least so far it doesn’t seem to decline over the first few years the way the other vaccine did.”

Is There A Downside To The Shingles Vaccine

Though the vaccine is deemed safe by the U.S. Food and Drug Administration , there are certain conditions in which the vaccine may not be safe for you.

• The shingles vaccine has only been tested in adults over age 50 years and immunocompromised adults above 18 years thus, there is no recommendation for the vaccine for younger ages by the FDA.
• You should not get the vaccine if you have had a severe allergic reaction to a previous Shingrix dose.
• You have tested negative for immunity to varicella-zoster virus .
• You have an active shingles infection.

Read Also: Tdap Vaccine Cvs

Can You Get The Shingles Vaccine For Free

The shingles vaccine is manufactured by GlaxoSmithKline Biologicals, a pharmaceutical company. GSK has a patient assistance program that may provide the vaccine to you at no cost if you meet these eligibility criteria:

• You dont have prescription drug coverage or a Part D plan and have spent at least $600 during the calendar year.
• You are an adult, 19 or older.
• You live in the U.S., Puerto Rico, or the District of Columbia.
• You dont qualify for Puerto Ricos Government Health Plan.
• Your maximum monthly gross income does not exceed certain limits, depending on where you reside and your household size.
• You apply through your health care provider, who will register for the patient assistance program and submit your application.

Vaccine Effectiveness And Safety

The vaccine reduces your chance of getting the virus by more than 50%, depending on your age. Vaccine effectiveness is higher among seniors between 65 and 70 years old.

No vaccine is 100% effective. If you get vaccinated, you may still develop shingles. But the infection would likely be less severe and youd be better protected from complications.

The vaccine has been licenced by Health Canada, having met all requirements under the Food and Drugs Act.

You May Like: Pertussis Vaccine Cvs

Mild Side Effects Of Shingles Vaccine:

• Redness, soreness, swelling, or itching at the site of the injection .
• Headache .

It is safe to be around infants and young children, pregnant women, or people with weakened immune systems after you get the shingles vaccine. There is no documentation of a person getting chickenpox from someone who has received the shingles vaccine .

Some people who get the shingles vaccine will develop a chickenpox-like rash near the place where they were vaccinated. As a precaution, this rash should be covered until it disappears.

Like all vaccines, shingles vaccine is being closely monitored for unusual or severe problems by CDC and FDA.

Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These would start a few minutes to a few hours after the vaccination. If you have a severe allergic reaction or other emergency that cant wait, call 9-1-1 or get the person to the nearest hospital. Otherwise, call your doctor.

Afterward, the reaction should be reported 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.

The shingles vaccine does not contain thimerosal .

This information was taken directly from the Shingles Vaccine Information Statement dated 10/06/2009.

The Problem With Medical Records Tracking Vaccine Schedules

Another obstacle is the fact that it can be difficult for family physicians to know exactly what vaccinations a patient has received. Unlike pediatric patients, who typically have accessible records of their vaccination schedule, it can be trickier for adults.

For adults, it becomes quite challenging, especially when they switch providers, because often times you have to track down records to find out if theyve been vaccinated, said Jain.

She said it can be complicated to try and decipher which vaccines patients have received and which ones they should get without clear records.

For adults over the age of 65, you want to find out if theyve gotten the two pneumonia vaccinations that are recommended, so it becomes a challenge to find out if theyve gotten both, or just one, she said.

Same thing goes now for the shingles vaccination. Youre kind of tracking down records, and when you dont have them, you have to make a clinical judgment.

Despite these challenges, Jain says the fact that Shingrix is a newly minted vaccination may make things a bit more straightforward.

The nice thing about Shingrix is that its so new, most patients have not gotten it, she said. Even if theyve had Zostavax, its recommended that they get Shingrix in addition to it, so thats a little bit less of a challenge with a new vaccination.

You May Like: Does Cvs Offer Tdap Shot

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.

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.

RELATED: Find a pharmacy near you

Read Also: Cvs Pharmacy Tdap Vaccine Cost

How Do You Get Immunised Against Shingles

You can only get the shingles vaccine on its own, not as a combination vaccine. It is given as a needle.

Shingles vaccines include:

• Zostavax – PDF 21 KB
• Shingrix PDF

Note the Zostavax vaccine contains a small amount of the live virus. Some people may not be able to receive a live vaccine for medical reasons, please discuss with your doctor or immunisation provider for further information.

Youre Our First Priorityevery Time

We believe everyone should be able to make financial decisions with confidence. And while our site doesnt feature every company or financial product available on the market, were proud that the guidance we offer, the information we provide and the tools we create are objective, independent, straightforward and free.

So how do we make money? Our partners compensate us. This may influence which products we review and write about , but it in no way affects our recommendations or advice, which are grounded in thousands of hours of research. Our partners cannot pay us to guarantee favorable reviews of their products or services.Here is a list of our partners.

Recommended Reading: Tdap At Cvs

How Well Does Shingrix Work

Two doses of Shingrix provides strong protection against shingles and postherpetic neuralgia , the most common complication of shingles.

• In adults 50 to 69 years old who got two doses, Shingrix was 97% effective in preventing shingles among adults 70 years and older, Shingrix was 91% effective.
• In adults 50 to 69 years old who got two doses, Shingrix was 91% effective in preventing PHN among adults 70 years and older, Shingrix was 89% effective.

Shingrix protection remained high in people 70 years and older throughout the four years following vaccination. Since your risk of shingles and PHN increases as you get older, it is important to have strong protection against shingles in your older years.

How Long Does Shingrix Last

The Shingrix vaccine can remain effective for at least four years in most people and even longer in others. You must get the entire series to be protected against shingles, which includes two separate shots. Even if you have had the infection, getting vaccinated can still offer benefits because it may help reduce the risk of developing PHN.

Shingrix may not protect everyone, but it provides broader protection for older adults whose immune systems are declining with age or disease.

Also Check: How Much Does Shingles Vaccine Cost At Cvs

How Does Medicare Cover The Shingles Vaccine

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.

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.

Read Also: How Much Does Tdap Cost At Cvs

Does Medicare Pay For Shingles Shots

Heres the quick answer

Surprisingly, Original Medicare doesnt cover the shingles vaccine, even though it covers other vaccines like the flu vaccine and pneumonia shot.

On the other hand, Medicare Part Dor a Medicare Advantage plan that includes Part D coveragetypically does cover the vaccine.

The devil is in the details

Every Part D plan is different, so your copay for a shingles vaccine could vary from one insurance plan to another. For this reason, its always good to check your plans formulary to see which vaccines they cover and which tier those medications fall under.

Part D covers a lot more than the shingles vaccine, providing coverage for prescription medications. If you need the shingles vaccine and prescription drug coverage, see our guide on how to find the best Part D plan for you, or learn more about Part D first.

I Have D Too And Mine Wouldn’t Cover It That Was A Few Years Back At My Local Drug Store

Recommended Reading: Tdap Vaccine At Cvs