If you experienced chickenpox at some point in your life, you are at risk of developing shingles. In essence, the shingles virus reactivates the chickenpox virus in the form of a painful rash on the torso. However, shingles can also lead to more severe complications like skin infections, chronic pain, and even vision loss. Fortunately, there is a shingles vaccine for adults aged 50 and over. So, does Medicare cover the shingles vaccine?
If you are a Medicare recipient, your insurance may cover the cost of the vaccine. However, the level of coverage will depend on a variety of factors, including the type of vaccine and your particular Medicare plan. Let’s first look at the coverage and cost of the shingles vaccine for Original Medicare recipients:
Original Medicare and the Shingles Vaccine
- Inpatient hospital care
- Hospice care
- Nursing home care
- Home health care
While Medicare Part B covers these health-related expenses:
- Doctor’s office visits
- Ambulance services
- Durable Medical Equipment (DME)
- Mental health care
- Outpatient hospital care
- Lab tests and bloodwork
- Preventative care
You might think that the shingles vaccine should be labeled “preventative care” and, therefore, qualify for Medicare Part B coverage. However, it is not.
In short, Original Medicare does NOT cover the cost of the shingles vaccine. So, if you only have Original Medicare (Parts A and B), you will have to pay full price for the shingles vaccination or acquire additional insurance.
Shingrix vs. Zostavax
It’s important to note that there are two distinct types of shingles vaccinations approved by the CDC: Shingrix and Zostavax. Manufacturers first put Zostavax on the market in 2011, while Shingrix came along in 2017. Both types are safe for adults aged 50 and older, with limited and mild side effects.
Regardless of the type of shingles vaccine, the shots do not eliminate the risk of shingles. That said, both vaccines significantly reduce the chances of developing the condition or experiencing some of the more severe complications. Studies show that Zostavax is 50-64% effective at preventing the onset of shingles in people between the ages of 50 and 70, though its efficacy decreases with age. Alternatively, Shingrix is 97% percent effective in people ages 50 and above. As a result, Shingrix is the most common option.
It’s also important to note that the effects of the shingles vaccine don’t last forever. Studies show that the vaccine protects people from getting shingles for about 4-5 years. In other words, you may need to get the shingles vaccine more than once to reduce the risk of developing the condition. Protection from shingles tends to last longer with Shingrix (about 5 years) than it does with Zostavax (about 4 years).
How much does the shingles vaccine cost?
Both types of shingles vaccines require two doses, though they vary in price. On average (and without insurance), Shingrix costs about $280 for both shots. Zostavax is about 20% cheaper, with average prices around $230 (prices vary by pharmacy and provider). Even though it is usually more expensive, Shingrix is the most commonly prescribed shingles vaccine (due to its high efficacy and duration).
When Does Medicare Cover the Shingles Vaccine?
Whether you take Zostavax or Shingrix, only prescription drug plans will cover the shingles vaccine. In other words, you will either need to have a stand-alone Part D plan or a Medicare Advantage Plan that includes Part D to get shingles vaccine coverage. All Medicare Part D plans are required to cover the shingles vaccine in some form.
Medicare Part D Coverage
You’ll have to check the Part D plan formulary to see how much you’re required to pay for the shingles vaccine. As Shingrix is the most common vaccine, there’s a good chance that your doctor will recommend Shingrix over Zostavax. Getting the Shingrix vaccine means that you may need to pay a little more, but not just because of the price tag.
Generally, Medicare categorizes Shingrix as a tier 3 drug, which means that it is almost always subject to the Part D deductible. So, if you haven’t paid your prescription drug deductible for the year, you’ll need to pay full price for your two Shingrix shots. However, once you’ve paid your deductible, Medicare Part D will typically cover at least 50% of the cost.
Agent TipPurchasing a Medicare Advantage plan or a stand alone Medicare Part (RX) plan can help lower your costs of the Shingles vaccine.
Ways to Save on the Cost of the Shingles Vaccine
The shingles vaccine is pretty expensive on its own. Even if you have Part D and have paid your deductible, you’ll need to pay up to $140 for Shingrix or $115 for Zostavax. Fortunately, there are a few ways to save on the cost of the shingles vaccine:
- Pay your deductible first – As previously mentioned, if you haven’t paid your prescription drug deductible for the year, you’ll need to pay full price for the shingles vaccine. The best way to save money is to pay your annual deductible before you get your vaccine shots.
- Research different Part D Plans – Some providers pay more for prescription drugs and vaccines than others. If you think a different provider would pay more for the shingles vaccine, consider switching your Part D or Medicare Advantage Plan during the Annual Enrollment Period.
- Look for coupons on GoodRx – Once you’ve exhausted all options through Medicare, you can look for shingles vaccine coupons on third-party websites like GoodRx.com. Not only can GoodRx help you save up to 35% on the shingles vaccines, but it can also point you to pharmacies and retailers with the lowest prices.
According to the Centers for Disease Control & Prevention (CDC), about 1 in 3 Americans will develop shingles during their lifetime. The condition can cause discomfort and potentially lead to more severe complications. As a result, any Medicare recipient who has had chickenpox should consider getting the vaccine.
Original Medicare doesn’t cover the shingles vaccine. To help pay for the vaccine, you will need to get a stand-alone Part D plan or a Medicare Advantage Plan that includes prescription drug coverage. So, does Medicare cover the shingles vaccine? The answer is ‘yes,’ as long as you have prescription drug coverage. However, you will still need to pay part of the cost.
thumbIf you have any questions about the shingles vaccine, Part D coverage, or cost-sharing Medigap options, learn more on our Medicare blog or call us at 800-208-4974 today!