Does Medicare Cover Shingrix (Shingles Vaccine)?

If you are over the age of 50, you are at an increased risk of developing shingles. The viral infection is a painful and itchy rash that usually appears on the torso, although it can show up anywhere on your body. You also might experience headaches, fever, and fatigue. 

Does Medicare Cover Shingrix?

Original Medicare (Part A and Part B) does not cover the shingles vaccines. To get coverage, you will need Medicare Part D; however, you may pay a portion of the vaccine. Medicare Part D is a prescription drug plan that covers the shingles vaccine and various other medications. 

Since Original Medicare covers most vaccines, many people wrongly assume that the shingles vaccine is covered. The shingles vaccine is quite expensive, so they have to pay a lot of money out of pocket.

What Is the Shingles Virus?

Shingles is a viral infection that induces an unpleasant rash on the body. Although shingles can spring up anywhere, it often forms a single stripe of painful blisters around the left or the right side of the torso.

“If you have had chickenpox, and that’s over 90% of adults, your immune system may have been able to keep the virus under control,” explains Shingrix. “The pain from shingles can be severe, disabling and may interfere with doing normal day-to-day activities including walking, sleeping and social activities.”

While shingles are not life-threatening, they can be very painful. Vaccines can help reduce the risk of shingles, while early treatment can help diminish a shingles flare-up and reduce complications.

Who Is at Risk of Shingles?

According to the national institute of aging,  1 in 3 people will get shingles in the United States. The risk of developing shingles increases with age.

Essentially, anyone who has had chickenpox can develop shingles, which is why doctors recommend having a shingles vaccine to those who are over the age of 50. Even if you’ve had shingles in the past, they can fare up again and again! 

What Are the Shingles Causes & Symptoms

Causes

Shingles and chickenpox are both caused by the same virus, the varicella-zoster virus. After you’ve had chickenpox, the virus lies dormant in nerve tissue near your spinal cord and brain. Years later, the virus can manifest as shingles.

Symptoms & Treatments for Shingles

Signs and symptoms of shingles typically affect only one side of the body:

• Pain, burning, numbness or tingling
• Sensitivity
• A red rash 
• Fluid-filled blisters
• Itching

Some people may have:

• A Fever
• A Headache
• Sensitivity to light
• Fatigue

How Can I Get Shingles Vaccine?

If you have prescription drug coverage through Medicare, you can get the shingles vaccine. However, you need to make sure you get vaccinated at a location that is covered by your plan. 

At the Pharmacy

Many seniors choose to get the shingles vaccine at local pharmacies. If the pharmacies do not participate in the Medicare drug plan, the vaccination won’t be covered. Therefore you should always check before getting vaccinated to ensure that you are covered.

At the Doctor’s Office

If you choose to get vaccinated by your doctor instead of at the Pharmacy, you need to find out if the plan will reimburse the doctor directly. Otherwise, you will have to pay for the vaccine and then get your prescription drug plan reimbursement. You can obtain the needed information by contacting your drug plan directly.

Do Medicare Part D Plans Cover the Shingles Vaccine?

To have your shingles vaccine covered, you can either get Medicare Part D to work along with Original Medicare or get a Medicare Advantage (Medicare Part C) plan that includes prescription drug coverage. Medicare Advantage plans usually have other benefits as well.

Getting Vaccinated

No matter if you choose to receive your Shingrix vaccination at the doctor’s office or Pharmacy, it’s the same. Shingrix is administered as a shot in the upper arm and provides strong protection between shingles and PHN. Two shots of Shingrix is over 90% effective at inhibiting shingles and PHN flare-ups. For the first four years after your vaccination, you will have 85% protection.  

How Much Does the Shingles Vaccine Cost?

Good RX breaks down the shingles vaccine as follows: 

Deductible co-pay range: $0-$164 

Typical: $0-$164 

Donut Hole: $0-$74 

Post Donut Hole: $7-$8

Side Effects of the Vaccine

According to the CDC, the following side effects are linked to the Shingrix vaccine: 

• a sore arm with mild or moderate pain 
• redness and swelling 
• fatigue
• muscle pain
• headache
• shivering
• fever
• stomach pain
• nausea

Find Affordable Medicare Plans

Medicare doesn’t cover Shingrix, but a prescription drug plan does. Talk to a licensed insurance agent to find out how to get the coverage you need. Whether you plan to add Medicare Part D to Original Medicare or call us for a Medicare Advantage plan, our agents will help you find coverage!

FAQ

Are There Any Restrictions on Coverage for Shingrix?

Most Medicare plans restrict the amount of Shingrix purchased at one time. If you need to buy more at once, it may not be covered. Your options are to wait until that period has passed before refilling, call your plan, and ask for an exception, pay out of pocket. 

What Drug Tier is Shingrix Typically On?

TIER 3

Medicare plans list Shingrix typically in Tier 3 as it is a preferred brand-name drug and costs more than Tier 1 and 2 drugs.

Why Does My Shingles Vaccine Cost So Much?

Unlike the flu and pneumonia vaccines covered under Medicare Part B, the shingles shot is covered as prescription drugs under Medicare Part D, and Medicare Advantage plans as it’s a ‘recommended’ vaccination and not one that is deemed necessary. 

That means if you haven’t met your annual deductible, you’ll likely wind up paying full price for the shot, which is about $217. Depending on your plan, consumers may have to pay a significant part of the shingles vaccine cost even after the deductible is met.

What Insurance Covers the Shingrix Vaccine?

All Medicare Part D plans cover the Shingrix vaccine, as well as Medicare Advantage plans with built-in Part D coverage.

Does Blue Cross Blue Shield Cover the Shingles Vaccine?

According to miblueperspectives.com, Blue Cross Blue Shield of Michigan and Blue Care Network cover the Shingrix vaccine at pharmacies across America.

Which Is Better Zostavax or Shingrix?

Shingrix is better than Zostavax. Shingrix is 97% effective at preventing shingles in those over 50. The Zostavax vaccine is just 50-64% effective in preventing shingles in those 50-70 and even less for those over 70.