Does Medicare Pay for a Shingles Shot?

Shingles, a viral infection caused by the varicella-zoster virus, can manifest as a painful rash with blisters. This condition stems from the same virus responsible for chickenpox, which can reactivate years later. Vaccination offers a way to reduce the risk of developing shingles and its potential complications. A vaccine is available and often recommended for eligible individuals.

Medicare Part D Coverage for Shingles Vaccine

The shingles vaccine, known as Shingrix, is typically covered under Medicare Part D. Medicare Part D, offered by private insurance companies, provides prescription drug coverage. This differs from Original Medicare, Parts A and B, which do not cover the shingles vaccine.

Coverage requires enrollment in a Medicare Part D plan, either a stand-alone Prescription Drug Plan (PDP) or a Medicare Advantage Plan (Part C) with drug coverage (MAPD). The vaccine is generally considered a prescription drug benefit under these plans.

The Inflation Reduction Act of 2022 significantly changed vaccine coverage under Medicare Part D. Starting in 2023, this legislation eliminated out-of-pocket costs for adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), including the shingles vaccine.

Costs Associated with Shingles Vaccine

As a result of the Inflation Reduction Act, individuals enrolled in Medicare Part D pay no out-of-pocket costs for the shingles vaccine as of January 1, 2023. Beneficiaries pay no deductibles, copayments, or coinsurance for the Shingrix vaccine. This $0 cost applies whether the beneficiary has a stand-alone Part D plan or a Medicare Advantage plan with drug coverage.

Prior to 2023, Medicare beneficiaries could face out-of-pocket expenses, such as deductibles or copays, for the shingles vaccine, which varied by plan. The legislative changes ensure that the cost of the vaccine itself, any dispensing fees, and administration fees are fully covered. While rare, some individuals might be asked to pay upfront and then seek reimbursement from their Part D plan.

Getting the Shingles Vaccine

The shingles vaccine can typically be obtained at either a pharmacy or a doctor’s office. Most Medicare Part D enrollees find it more straightforward to receive the Shingrix vaccine at a pharmacy. This is because more than 95% of Part D enrollees receive their shingles vaccine at a pharmacy, as many doctor’s offices may not directly bill Part D for vaccinations.

If choosing to get the vaccine at a doctor’s office, it is advisable to confirm with the office if they can bill your Part D plan directly or if you will need to pay upfront and then seek reimbursement. When getting the vaccine, individuals should be prepared to provide their Medicare card and information about their specific Part D plan. Contacting your Part D plan or the chosen vaccination site beforehand can help confirm coverage details and procedural requirements.

Enrolling in Medicare Part D

To enroll in a Medicare Part D plan, individuals must first have Medicare Part A or Part B. They must also be a U.S. citizen or lawfully present in the U.S. and reside within the service area of the plan they wish to join.

Most individuals become eligible for Medicare Part D during their Initial Enrollment Period (IEP). This seven-month period includes the three months before turning 65, the month of the 65th birthday, and the three months after. For example, if someone turns 65 in May, their IEP runs from February 1 to August 31.

If the IEP is missed, individuals can enroll during the Annual Enrollment Period (AEP), which runs from October 15 to December 7 each year, with coverage beginning on January 1 of the following year. Delaying enrollment in Part D without other creditable prescription drug coverage can result in a late enrollment penalty, added to the monthly premium for as long as the individual has Part D coverage. Special Enrollment Periods may also be available under certain circumstances, such as moving or losing other creditable coverage.