Does Medicare Cover Shingrix?
Shingles, or herpes zoster, is a common disease that is caused by the same virus as chickenpox. If you had chickenpox as a child, this virus can stay in your nerve cells and reactivate as shingles when you’re older. Approximately 50 percent of all cases of shingles in the United States occur in those who are over 60 years old. But the risk increases even more when you reach your 70s.
In most cases, shingles isn’t a dangerous disease, but it can be painful and uncomfortable due to symptoms like inflamed skin rash and fluid-filled blisters. In some instances, it can cause eye damage, blindness, hearing loss, facial paralysis, or inflammation of the brain.
Fortunately, there is an effective vaccine that you can get to prevent yourself from getting shingles and the related complications. The CDC recommends that if you’re 50 or older, you should ask your health care provider about getting the two-dose Shingrix vaccine for protection.
Shingrix is one of the most common vaccines prescribed for patients older than 50 for the prevention of herpes zoster (shingles). Medicare coverage may help you cover the cost of a prescription for Shingrix.
Does Medicare cover the Shingrix vaccine?
Original Medicare Part B (outpatient medical insurance) typically covers 100 percent of the cost for some vaccines that are categorized as preventive. Unfortunately, Shingrix doesn’t fall into this category.
Medicare Part B covers the following preventive vaccines:
- Hepatitis B for those who are at medium to high risk
- Influenza (on an annual basis)
- Pneumococcal
- Tetanus, rabis, etc.
- Vaccines and boosters that reduce the risk of severe illness such as COVID-19
Medicare Part D may provide your coverage for Shingrix. To get coverage for your Shingrix vaccine, you must rely on prescription drug coverage. Everyone who is eligible for Medicare can get coverage either through a stand-alone Medicare Part D plan or from a Medicare Advantage (Part C) plan that includes prescription drug coverage. Either way, this Medicare drug coverage may help you pay for prescription drugs you need.
All Medicare Part D plans are required to cover a wide range of prescription medications that are commonly taken by Medicare enrollees. On the other hand, they also have the option to include or exclude other drugs from the plan’s formulary (list of covered drugs).
Shingrix is one of the common drugs that all Medicare prescription drug plans are required to cover, so you won’t have a problem getting coverage for it if you’re enrolled in a Medicare prescription drug plan.
Medicare prescription drug plans categorize the drugs included on their formularies into different levels known as tiers. Each tier of drugs carries a different cost – or copayment. Most Medicare prescription drug plans list Shingrix on tier three of the formulary. Tier three typically includes high-cost brand-name drugs. Your copayment depends on the amount set by your provider.
Should you get vaccinated against shingles?
Your health care provider might suggest you get vaccinated for protection against the virus that causes shingles (herpes zoster) if any of the following is true for you:
- You’ve had chickenpox or shingles, or you’ve been vaccinated for chickenpox.
- You were vaccinated for shingles, but it was the Zostavax vaccine.
- You don’t remember if you had chickenpox.
You should notget the shingles vaccine if any of the following are true:
- You currently have shingles.
- You are currently ill or have a fever.
- You had an allergic reaction to a previous shingles vaccine.
How much does Shingrix cost without Medicare insurance?
If you are a Medicare beneficiary, but you don’t have prescription drug coverage, you must pay for the Shingrix vaccine yourself.
The amount you pay depends on where you live, what plan you have, and where you purchase it. The national average cost of one dose of Shingrix, which requires a two-dose regimen, is approximately $150.00. With Medicare Part D coverage, most patients only pay a copayment or coinsurance.