Medicare does cover the shingles vaccine at 100%. Shingles vaccination is exempt from the Medicare plan’s deductible.
Effective January 01, 2023 the shingles vaccine, Shingrix, is available for free to all Medicare beneficiaries with prescription drug benefits.
Does Medicare Part B Cover Shingles Vaccine?
Medicare Part B typically covers medications administered by a medical professional, but not the shingles vaccines.
Part B vaccines include those for flu, pneumonia, Hepatitis B, Wuhan Flu and other vaccines that are less common.
If a vaccine is not covered by Part B, it should be covered by your Medicare Part D prescription drug coverage. Most all commercially available vaccines are covered under Medicare Part D drug coverage, except those already covered by Part B. This includes the Medicare prescription drug plans bundled with a Medicare Advantage plan. Both will cover the shingles vaccine.
Does Medicare Cover Shingrix Vaccine?
The Shingrix vaccine is covered under your Medicare Part D prescription drug plan.
The newly passed Inflation Reduction Act has changed what an insurance company can charge for the vaccine as of January 01, 2023. Prior to January 2023 the decision on what to charge for shingles vaccine coverage was up to each individual Medicare prescription drug plan.
As of 2023 all Medicare Part D prescription drug coverage plans must offer the Shingrix vaccine free of charge. It does not matter if you have a Original Medicare and stand-alone Part D prescription drug coverage or a Medicare Part D prescription drug plan that is bundled with your Medicare Advantage Plan (MAPD). Every Medicare plan is now required to offer the vaccine at no cost to the consumer. Medicare beneficiaries can get the shingles vaccine with no out of pocket cost.
How Much Does the Shingles Vaccine Cost?
Without a Medicare prescription drug plan, Medicare beneficiaries could pay between $150 and $200 for the Shingrix vaccine.
With Medicare prescription drug benefits, your out of pocket costs will be zero for a shingles vaccine. It does not matter whether your coverage comes from Medicare Part D plans or a Medicare Advantage plan. Your Medicare coverage includes the shingles shot at 100%
For those under 65, your employer group coverage or ACA plan should also cover a shingles vaccine at 100%.
What is Shingles?
Shingles is a viral infection caused by the same virus that causes chicken pox, the varicella-zoster virus. 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. 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 shingles vaccine as effective as Shingrix, these chicken pox parties are simply not necessary. The vaccine 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. 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 sever 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 a Shingles Vaccine?
The Centers for disease control and prevention (CDC) recommends that all adults 50-years of age and older get the shingles vaccine by receiving two doses of Shingrix. The two doses of shingles vaccine should be administered between two and six months apart.
People with weakened immune systems who are age 19 and older should also get the shingles vaccine , if needed. Older adults, age 50 and older should also consider the vaccine.
The shingles vaccine should be available at your doctor’s office and most pharmacies. It is highly recommended that you make certain you use an in network pharmacy. Check with your Medicare Part D plan or Medicare Advantage plan to be certain of your drug plan’s network.
Who Should Not Get the Shingles Vaccine?
As with all vaccines, they are only intended to prevent a disease you do not have.
Once you develop shingles you should not seek a vaccine to treat your disease. If you currently have shingles, or believe you have shingles you should not get the shingles vaccine.
The shingles vaccines come 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 taking the shingles vaccine.
How Do I Get a Shingles Vaccine?
You can get a shingles vaccine at your doctor’s office or a pharmacy. You do not need a doctor’s prescription. Your Medicare Part D plan will cover the shingles vaccine when administered at either the doctor’s office or the pharmacy. But you should take care to be certain the pharmacy is in you prescription drug plan network. Otherwise, there could be a cost to the shingles vaccine.
No matter which option you choose to get the shingles shot, shingles shots 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 vaccine is 91% effective for those age 70 and older. These statistics refer to people with health 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 of the Shingrix?
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 ither muscle pain. Some people develop flu like symptoms that include a mild fever, headache, stomach pain and nausea and possible a fever.
Shingles 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 shingles shot, you should immediately consult your healthcare professional. A second shot would not likely be recommended.
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 the Shingles?
Of all the possible side effects of shingles, 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. I believe the potential for PHN alone is worth getting the vaccine as early as you can.
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
Matthew Claassen
Matthew Claassen, CMT and CEO of Medigap Seminars Insurance Agency. Medigap Seminars is an award winning premier national Medicare Insurance Brokerage, ranked among the top in the U.S.A. Matthew is considered a leading national expert on Medicare and Social Security. Mr. Claassen is a distinguished member of the Forbes Business council, an invitation only organization of business leaders and entrepreneurs. He and his team have received awards from many of the countries largest insurance companies including Mutual of Omaha, Aetna, Humana, Cigna, United American, United Healthcare and others. His videos have become the most popular Medicare educational videos on YouTube with millions of views. As a financial analyst Matthew lead a team of researchers to win the 2009 Best Equity Research & Strategy Award from The Technical analysis magazine.
