Does Medicare Cover the Shingles Vaccine?

The risk of developing shingles, a painful rash caused by the reactivation of the chickenpox virus, increases with age. The shingles vaccine is a preventive measure designed to reduce the likelihood of contracting the disease and its potential long-term complications, such as postherpetic neuralgia. Understanding how Medicare covers this vaccine is important for older adults.

Medicare Coverage for Shingles Vaccine

The shingles vaccine, known as Shingrix, is covered under Medicare Part D, which includes prescription drug plans, because it is classified as a prescription drug. Medicare Part D plans are offered by private insurance companies that contract with Medicare.

This differs from Medicare Part A, which covers inpatient hospital care, and Medicare Part B, which covers outpatient medical services. Neither Part A nor Part B covers the shingles vaccine as a standalone benefit. Medicare Part B does cover other vaccines, such as flu shots, pneumococcal shots, and hepatitis B shots for individuals at risk.

These specific vaccines are covered under Part B as preventive services, typically with no out-of-pocket cost. However, the shingles vaccine’s classification as a prescription drug places its coverage within Part D plans. To receive coverage, individuals must be enrolled in a Medicare Part D plan, either as a standalone plan or as part of a Medicare Advantage Plan (Part C) that includes drug coverage. Coverage details, including in-network pharmacies or providers, depend on the individual Part D plan.

Understanding Your Costs

Out-of-pocket costs for the shingles vaccine under Medicare Part D are not fixed and vary based on the plan’s structure. Most Part D plans include a deductible, an amount you pay for prescription drugs, including the vaccine, before your plan contributes. Once the deductible is met, you will be responsible for a copayment (fixed dollar amount) or coinsurance (percentage of the vaccine’s cost).

The amount of this copayment or coinsurance depends on your plan’s formulary, which categorizes drugs into different tiers, each with its own cost-sharing level. Vaccines may be placed in a preferred or non-preferred tier, influencing your out-of-pocket expense. Costs for each dose commonly range from $0 to over $100, depending on the plan and whether the deductible has been satisfied. To understand your precise costs, contact your Medicare Part D plan provider directly. They can provide accurate information regarding your deductible status, the specific cost-sharing for the shingles vaccine, and any network requirements.

Steps to Get Your Vaccine

The shingles vaccine can be administered at a wide range of locations, including retail pharmacies, physician’s offices, and public health clinics. Many pharmacies are equipped to administer the vaccine and are often the most convenient option, as they can directly bill your Part D plan.

When you get your vaccine, ensure you have your official Medicare card and your Medicare Part D plan card. These cards contain the necessary identification numbers and plan details for the provider to verify eligibility and submit the claim. The administering provider will typically confirm your coverage details and inform you of any out-of-pocket costs you might owe at the time of service. It is always a prudent step to call ahead to your chosen pharmacy or doctor’s office to confirm they stock the shingles vaccine and can bill your specific Medicare Part D plan.