There’s a lot that your Medicare insurance plan can cover. From hospital bills to prescription pills, it should help you afford the health care you need. But as we’ve covered before, there are gaps in what Medicare, even Medigap(!), plans can and do cover.
Whenever there’s a new or increasingly popular medication in the United States, the question of coverage inevitably follows. With the new Shingrix vaccination available, the question of whether Medicare insurance covers the shingles vaccine has grown from a whisper to a roar. This is especially true since the Shingrix vaccination is so effective (97 percent for adults ages 50 to 69 and 91 percent for adults ages 70 and older). The CDC even recommends Shingrix over Zostavax, the previous shingles vaccination.
So, does the Medicare program cover the shingles vaccination?
What Is Shingles?
First, let’s discuss what shingles is a bit. Shingles is a painful condition that flares up in a small area on one side of the body.
Herpes zoster, the scientific name for shingles, is caused by the varicella zoster virus. This is the same virus that causes chickenpox as a kid. Once you get chickenpox, the virus remains in your nervous system in an inactive state. It can reactivate later in life, causing a bout of shingles.
Once you get chickenpox, the virus remains in your nervous system in an inactive state, sometimes reactivating as shingles later in life.
The general symptoms include pain or a burning sensation, itchiness, fluid-filled blisters, and a red rash. Sometimes, people will also experience fevers, headaches, sensitivity to light, and fatigue. The other symptoms tend to follow pain, which is sometimes intense. Generally, these symptoms can last for two to four weeks.
What Should I Do If I Have Shingles?
If you suspect you’ve developed shingles, you should contact your doctor right away. While shingles isn’t life-threatening, early detection and treatment can greatly shorten the amount of time you have the illness. You should especially contact your doctor if you’re 60 or older or have a weakened immune system, as these factors can greatly increase your chances of complications.
Does the Medicare Program Cover the Shingles Vaccination?
The answer is a resounding… maybe. If you’re enrolled in only Original Medicare (Medicare Parts A and B) then no, it’s not covered. Medicare Parts A and B cover many things, including select hospital and preventative care services. While vaccinations do prevent illness, not all of them are covered by Medicare Part B (the part of the Medicare program that covers medically necessary services, like doctor visits). In fact, if you have Medicare Part B, only three kinds of vaccines are generally covered — the flu, pneumococcal disease, and hepatitis B vaccines.
How Medicare Insurance Can Cover the Shingles Vaccine
The shingles and Tdap (tetanus, diphtheria, and pertussis) vaccines are considered to be medications, meaning that they would fall under the possible coverage of Medicare Part D. Generally, they, and other commercially available vaccines, are covered by Part D plans, though the specifics of this can change from plan to plan. Medicare Part C plans that include drug coverage may also include vaccinations, like the Shingrix vaccine. Different plans cover different sets of prescription drugs and vaccinations, though.
Generally, the shingles and Tdap vaccines, and other commercially available vaccines, are covered by Medicare Advantage Prescription Drug and stand-alone Part D plans, though specifically what’s covered is different between plans.
How to Know If Your Plan Covers the Vaccine
To verify if your Medicare Part C or D plan covers a certain vaccination, you should check your plan’s formulary. Coverage can also depend on your plan’s network, since it may not be covered if you get it at a pharmacy or doctor’s office outside your network. While most plans should cover the Shingrix vaccination by now, if your plan doesn’t, you can try to request a formulary exception to have it covered.
What You May Still Have to Pay
Even if your Part C or D plan covers the shingles vaccine, you may still be responsible for a copay or coinsurance for the shot. Also, if you receive the vaccination in the doctor’s office, you may not be covered initially. If your doctor doesn’t work with a pharmacy in your plan or bill your Medicare Part D or C plan directly, you may be charged up front. You can put in a claim to your plan for reimbursement after the fact, though.
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The shingles vaccination is a worthwhile measure to prevent a painful and common disease. With so many of us catching chickenpox as children, there’s a good chance you may already have the virus in your system. That’s why it’s so helpful that the Medicare program usually covers the shingles vaccination in some way. By removing another barrier to get inoculated, it’s even easier for many to avoid this very preventable illness.