Yes, Medicare does cover the shingles vaccine, but coverage depends on your Medicare plan. As of 2023, the shingles vaccine—including Shingrix—is covered at no cost to beneficiaries under Medicare Part D prescription drug plans. This means if you’re enrolled in a standalone Part D plan or a Medicare Advantage plan with drug coverage, you can receive the shingles vaccine without a copay when administered at an in-network pharmacy or provider. Original Medicare (Part A and Part B) does not cover the shingles vaccine. Knowing how Medicare covers the shingles vaccine is essential for preventing shingles and avoiding out-of-pocket costs.
Shingles is a painful and potentially serious condition caused by the reactivation of the varicella-zoster virus, the same virus responsible for chickenpox. To prevent this distressing illness and its complications, many adults consider getting the shingles vaccine. Understanding Medicare coverage for the shingles vaccine is essential for those eligible to ensure they receive this important preventive care without unexpected costs. This article will guide you through what shingles is, who should get the shingles vaccine, and how Medicare supports coverage for this vital immunization.
Key Takeaways
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Shingles is caused by the reactivation of the varicella-zoster virus, which also causes chickenpox.
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The shingles vaccine, Shingrix, is highly effective and recommended for adults aged 50 and older, as well as certain younger individuals with weakened immune systems.
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Medicare Part D and Medicare Advantage plans with prescription drug coverage cover the shingles vaccine, while Original Medicare (Parts A and B) does not.
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The vaccine requires two doses spaced two to six months apart for full protection.
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Getting vaccinated can prevent painful complications such as postherpetic neuralgia (PHN).
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It is important to use in-network providers or pharmacies to avoid out-of-pocket costs.
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Common side effects are generally mild and temporary.
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Always consult your healthcare provider for personalized advice and to confirm your Medicare plan’s coverage details.
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What is Shingles?
Shingles is a viral infection caused by the same virus that causes chicken pox, the varicella-zoster virus, which falls under the category of infectious diseases. If you had chicken pox as a child, the virus lies dormant in your body and may reemerge as shingles later in life.
According to the CDC, more than 99% of U.S. Citizens born before 1981 have had the chicken pox disease, which is significant in discussions about medicare part b. Many contracted chicken pox at such a young age that they don’t remember.
Chicken pox parties were very common pre-1980. A check pox party is when parents would intentional have a meetup to spread the disease amongst their children. The understanding was that chicken pox was much less severe at a young age. Now, with a vaccine as effective as Shingrix, these chicken pox parties are simply not necessary. The immunization is considered safer than early exposure to the disease.
What Are the Symptoms of Shingles?
Shingles is a painful rash that typically affects one side of your body, usually your torso, which can be prevented by getting the shingles shot. It is often painful and sensitive to the touch. The rash often becomes visible a few days after you notice the pain and develops into fluid-filled blisters that can break open and start itching.
In addition to a rash, other symptoms may include fever, headaches, fatigue and sensitivity to light.
Are There Possible Complications with Shingles?
The most common complication of shingles is a condition called postherpetic neuralgia (PHN).
Only about 10% to 13% of people with shingles will develop PHN. However, it can be severe and so debilitating that it interferes with your quality of life, possibly for the rest of your life. The potential for severe PHN increases with age. The older you are, the more likely you are to develop PHN and the more severe it is likely to be.
According to the CDC, other complications from shingles include brain inflammation (encephalitis), hearing problems, pneumonia and even death. Other complications of shingles and a more detailed discussion can be found on the CDC website.
Who Should Get the Vaccine and Does Medicare Cover It?
The Centers for Disease Control and Prevention (CDC) recommends that all adults 50-years of age and older get vaccinated by receiving two doses of Shingrix. The Advisory Committee on Immunization Practices (ACIP) recommends the immunization for adults 50 years and older, ensuring it is covered under Medicare Part B and Part D without any costs to beneficiaries. The two doses of Shingrix should be administered between two and six months apart.
People with weakened immune systems who are age 19 and older should also get the vaccine, if needed. Older adults, age 50 and older should also consider the shot as part of their preventive services.
Vaccinations should be available at your doctor’s office and most pharmacies, provided that the provider accepts medicare. It is highly recommended that you make certain you use an in-network pharmacy. Check with your Part D plan or Medicare Advantage plan to be certain of your drug plan’s network so there is no cost sharing.
Who Should Not Get the Shot?
As with all vaccines, they are only intended to prevent a disease you do not have. Once you develop shingles you should not seek immunization to treat your disease. If you currently have shingles, or believe you have shingles you should not get the vaccine.
The vaccine comes in two doses. If you have a severe allergic reaction to the first dose, it is not recommended you take the second dose.
In addition, if you are already ill with a moderate to severe illness you should wait until you have recovered before receiving the vaccine.
How Do I Get Vaccinated with Medicare Part D Drug Coverage?
You can get the immunization at your doctor’s office or a pharmacy. You do not need a doctor’s prescription. Your Medicare prescription drug plans (Part D) will cover the cost when administered at either the doctor’s office or the pharmacy. But you should take care to be certain the pharmacy is in your prescription drug plan network. Otherwise, there could be a cost.
No matter which option you choose to get the shot, it should be exempt from your plan’s deductible with no cost to you.
How Effective is Shingrix?
The CDC statistics show that Shingrix is 97% effective at preventing shingles in adults 50 to 69 years of age. The vaccination, particularly with Shingrix, is highly recommended for adults aged 50 and older to prevent shingles and its complications. The immunization is 91% effective for those age 70 and older. These statistics refer to people with healthy immune systems. In adults with less than healthy immune systems the vaccine was still between 68% and 91% effective.
It should be noted that a shingles vaccine called Zostar (Zostavax) is no longer available in the United States as of November 18, 2020. CDC recommends that those who had the Zostar vaccine also get Shingrix. As always, please consult your healthcare provider. The effectiveness of the Zostar vaccine decreases with age and it was never as effective as Shingrix.
What are the Possible Side Effects?
As with all vaccines, there may be temporary side effects lasting two to three days. This may include a sore arm with mild swelling near the injection site or other muscle pain. Some people develop flu-like symptoms that include a mild fever, headache, stomach pain and nausea and possibly a fever.
Side Effects Duration
These side effects seldom last more than a few days. If they last more than three days you should consult your healthcare provider.
If you develop a severe allergic reaction after your first dose, you should immediately consult your healthcare professional. A second dose would not likely be recommended in this case.
On rare occasions, Guillain-Barre syndrome (GBS) has been reported. GBS is a nervous system disorder. Interestingly, GBS is also a rare side effect of shingles.
What Are the Serious Side Effects?
Of all the possible side effects, the two most serious are PHN and GBS as detailed above.
GBS is rare and is also a potential of the disease. PHN is less rare and can be life changing. The potential for PHN alone is worth getting vaccinated as early as you can.
Medicare Coverage for Shingles Prevention
Medicare coverage for shingles prevention is primarily available through Medicare Part D prescription drug plans and Medicare Advantage plans that include drug coverage, aligning with the medicare contract. It’s important to note that Original Medicare (Part A and Part B) does not cover this immunization. However, thanks to the Inflation Reduction Act of 2022, Medicare Part D and Medicaid are now required to cover Shingrix starting from January 2023.
Medicare Part D plans are mandated to cover all commercially available vaccines necessary to prevent illness, except for those covered under Part B. Since shingles prevention is considered a preventive service, it falls under the shingles vaccine coverage of Medicare Part D. Similarly, Medicare Advantage plans that offer prescription drug coverage will also pay for the immunization.
It’s crucial for beneficiaries to understand that Medicare plan coverage can vary depending on the specific plan and provider, including options available through the state medicaid program. Therefore, reviewing your plan’s formulary, consulting with your healthcare provider, and enrolling in Medicare is essential to grasp the coverage details and any potential out of pocket costs. This proactive approach ensures you are well-informed about your Medicare plan coverage and can take full advantage of the benefits available to you.
FAQ About Shingles Vaccines and Medicare
Yes, Medicare plans cover the immunization shingles shot primarily through Medicare Part D prescription drug plans and Medicare Advantage plans that include prescription drug coverage. Original Medicare (Parts A and B) does not cover it.
The vaccine requires two doses administered between two and six months apart for full effectiveness.
Most Medicare Part D and Medicare Advantage plans cover the vaccine with no out-of-pocket costs, especially if you use an in-network provider or pharmacy. However, coverage details can vary by plan, so it is recommended to check your specific plan’s formulary.
The Centers for Disease Control and Prevention (CDC) recommends that all adults aged 50 and older receive the immunization, similar to most vaccines aimed at preventing infectious diseases. People with weakened immune systems aged 19 and older should also consider vaccination.
Yes, it is available at many pharmacies and doctor’s offices. Be sure to use a pharmacy that accepts your Medicare Part D plan to avoid extra costs.
Common side effects include soreness and mild swelling at the injection site, muscle pain, fever, headache, and fatigue. These side effects typically last a few days.
Yes, Shingrix is about 97% effective at preventing shingles in adults aged 50 to 69 and about 91% effective in those 70 and older.
No, the vaccine is intended to prevent shingles and should not be used to treat an active shingles infection. Wait until you have fully recovered before getting vaccinated.
Medicare Part B covers certain vaccines like the flu shot and pneumococcal vaccines, while Part D covers other vaccines including shingles and respiratory syncytial virus (RSV) vaccines. Coverage depends on the vaccine and plan.
If you experience a severe allergic reaction after the first dose, consult your healthcare provider immediately. A second dose is generally not recommended in this case.
References
Centers for Disease Control and Prevention (CDC – cdc.gov/vaccine)
https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/
Kaiser Family Foundation – kff.org
Mayo Clinic – mayoclinic.org
Medical News Today: https://www.medicalnewstoday.com/articles/323728
