Does Medicare Cover the Shingles Vaccine?

Does Medicare Cover the Shingles Vaccine? What You Need to Know.

Most people over the age of 50 know about Shingles, because they’ve heard about how awful it can be from a friend. In case you didn’t know, Shingles is a viral infection (the same virus that causes chickenpox!) that causes a painful blistery rash. Anyone who has had chickenpox is at risk of getting Shingles. The rash commonly appears on the torso, although it can occur anywhere on your body. The pain can be intense, which brings us to our real topic today: the Shingles vaccine. 

The short answer is YES! Medicare does cover the Shingles vaccine. However, as with most Medicare-related questions, the cost depends on your Medicare Part D Prescription Drug Plan. Medicare Part D is the part of your Medicare program that covers the Shingles shot, not original Medicare. 

Original Medicare which is Medicare Part A (Hospital Insurance) or Medicare Part B (Medical Insurance), does not cover the shingles vaccination.  Generally speaking, the Shingles vaccine is covered under your Medicare prescription drug plan (Part D) or Medicare Advantage plan (Part C). However, your actual cost and coverage will depend on the specifics of your plan. If you don't have a prescription drug plan, the full price for two doses of the Shingles vaccine (known as Shingrix) is $324. The most effective method to prevent Shingles is to have two doses of the vaccine two to six months apart. 

How Much Does the Shingles Vaccine Cost with Medicare?

Every Medicare Part D plan is different so the amount you pay will vary based on your policy details, copay, and the amount of your deductible. For some the shingles vaccine could be free whereas others may pay full price ($324) if a deductible must be met before the cost-sharing benefits begin.

How Much Will You Pay for Shingles Vaccines?

It’s important to know what to expect before you make an appointment for your Shingles vaccine. You can find the shingles vaccine on your Part D plan formulary or listing of covered medications. It is important to check and see which tier the vaccine falls on your Part D plan; the tier will define how much your insurer will pay and how much you will have to pay.

If your doctor’s office will provide the vaccination, it is also important to confirm that they can bill your plan directly. That way, you’ll have only the copay. Otherwise, you may have to make the full payment upfront and file with your plan for reimbursement. We also recommend that you check to be sure that the doctor’s fee for administering the shot is covered as part of your plan’s allowable charge.

If you want to save money on the Shingles vaccine, you might consider being vaccinated at a pharmacy that’s within your Part D drug plan’s network. But if you haven’t met your deductible for the year on your drug plan, you may pay full price for the vaccine. Check with your Plan D and then make a call to your local pharmacy to find out how they handle Shingles vaccines. 

How does Your Medicare Deductible Affect Your Vaccine Costs?

Even though all insurance plans for Medicare Part D offer some level of coverage for the shingles vaccine, the typical cost for the vaccine will vary. Your actual cost will depend on your plan details and if you've already met your deductible.

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 look at two examples: 

  1. You are enrolled in a Medicare Part D Prescription Drug plan that has a $480 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 $324 for two doses. 
  2. You are enrolled in a no-deductible Medicare Part D Prescription Drug plan. The cost of the shingles vaccine would be a copay amount for tier 3 drugs, per the plan’s formulary. In this case, let’s say the plan indicates there is a $45 copay for tier 3 dugs like the shingles vaccine. Because there is no deductible to meet on this plan, the copay for two doses of the shingles vaccine would be $90. 

Keep in mind that this comparison is only looking at the cost of the shingles vaccine and isn't taking into consideration any other medication costs. If you regularly take prescription drugs, the most appropriate prescription drug plan for you could be one that has a higher monthly cost, with no deductible, or a lower monthly cost with a deductible. Instances like these are exactly why it is so important to work closely with an agent who specializes in Medicare, so your specific medical and financial needs are met.  

Why doesn't Medicare Cover the Shingles Vaccine for Free for All Seniors?

Perhaps because Covid-19 has set a precedent, many people think any vaccine recommended by the CDC for those over age 50 is fully covered by Original Medicare. Here are some of the reasons why you may end up paying 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.

At Jbird Insurance Group, we are invested in your financial and physical well-being. Don’t put off getting important vaccines like the Shingles shot because you are unsure of any associated costs. Let us help find the right Medicare plan for you!