Does Medicare Cover Shingles Vaccines like Shingrix?
There’s a lot that a beneficiaries Medicare plan can cover. From hospital bills to prescription pills, it should help them afford the health care they need. But 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 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 Medicare cover the shingles vaccination?
What Is Shingles?
First, let’s discuss what shingles is. 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.
Shingles is a painful condition that flares up in a small area on one side of the body. It can last for two to four weeks. 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.
If a beneficiary suspects they have developed shingles, they should contact their doctor right away. While shingles is not life-threatening, early detection and treatment can greatly shorten the amount of time they have the illness. They should especially contact their doctor if they are 60 or older or have a weakened immune system, as these factors can greatly increase their chances of complications.
Does Medicare Cover the Shingles Vaccination?
The answer is a resounding… maybe. If a beneficiary is 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 Medicare that covers medically necessary services, like doctor visits). In fact, if they have Medicare Part B, only three kinds of vaccines are generally covered — the flu, pneumococcal disease, and hepatitis B vaccines.
The shingles and tdap (tetanus and diphtheria) vaccines are considered to be medications, meaning that they would fall under the coverage of Medicare Part D. Generally, they, and other commercially available vaccines, are covered by Part D plans. 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.
To verify if a beneficiary’s Medicare Part C or D plan covers a certain vaccination, they should check their plan’s formulary. Coverage can also depend on their plan’s network, since it may not be covered if they get it at a pharmacy or doctor’s office outside their network. While most plans should cover the Shingrix vaccination by now, if a beneficiary’s plan doesn’t, they can try to request a formulary exception to have it covered.
Even if their Part C or D plan covers the shingles vaccine, they may still be responsible for a copay or coinsurance for the shot. Also, if they receive the vaccination in the doctor’s office, they may not be covered initially. If their doctor doesn’t work with a pharmacy in their plan or bill their Medicare Part D or C plan directly, they may be charged up front. Beneficiaries can put in a claim to their plan for reimbursement after the fact, though.
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 Medicare 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.
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