Shingles, also known as herpes zoster, is a viral infection that can cause a painful, blistering rash. It affects people who have had chickenpox in the past, as the virus remains dormant in the body and can reactivate later in life. The shingles vaccine is an effective way to reduce the risk of developing shingles and its complications. Many people who are eligible for the vaccine wonder whether insurance companies will cover the cost. In this article, we’ll explore how insurance companies handle coverage for the shingles vaccine, what factors influence coverage, and what you should know before getting vaccinated.
What is the Shingles Vaccine?
The shingles vaccine is designed to prevent shingles and its potential complications, such as postherpetic neuralgia, a condition that causes persistent pain even after the rash has healed. There are two main types of shingles vaccines:
Zostavax: This is the older vaccine and is a live vaccine, which means it contains weakened live virus to stimulate the immune system. It was recommended for people aged 60 and older but has been largely replaced by Shingrix.
Shingrix: This is the newer vaccine and is preferred by health experts because it offers better protection against shingles. Unlike Zostavax, Shingrix is a non-live, recombinant vaccine, meaning it does not use any live virus. It is typically recommended for adults aged 50 and older and is given in two doses, spaced two to six months apart.
The Centers for Disease Control and Prevention (CDC) recommends Shingrix as the preferred vaccine for adults aged 50 and older.
Why Should You Get Vaccinated?
Shingles is more common in older adults because immunity to the chickenpox virus weakens over time. The pain associated with shingles can be severe, and in some cases, the rash can cause permanent scarring or nerve damage. Even after the rash heals, some people experience nerve pain that can last for months or even years. Vaccination is the best preventive measure.
The shingles vaccine reduces the risk of developing shingles and can also make the disease less severe if it does occur. For example, Shingrix is shown to be about 90% effective at preventing shingles.
Do Insurance Companies Cover the Shingles Vaccine?
Whether or not insurance companies pay for the shingles vaccine depends on several factors, including the type of insurance plan you have and the age and health status of the person being vaccinated. Let’s take a closer look at how different types of insurance may cover the vaccine.
Medicare and Shingles Vaccination
Medicare is a government health insurance program for people aged 65 and older. There are two parts of Medicare that may cover the shingles vaccine:
Medicare Part B (Medical Insurance): Medicare Part B generally does not cover vaccines like the shingles vaccine. However, it does cover certain vaccines, such as flu shots and pneumococcal vaccines. Since the shingles vaccine is a preventive service and not a medically necessary treatment for an existing condition, Medicare Part B does not cover it.
Medicare Part D (Prescription Drug Plan): Medicare Part D is more likely to cover the shingles vaccine. Part D is a prescription drug plan that covers vaccines that are recommended by the CDC, including Shingrix. If you have Medicare Part D, your plan will typically cover the cost of the vaccine, but you may still have to pay a copayment or coinsurance. The cost of the vaccine can vary depending on your plan and whether you get it from an in-network pharmacy or a doctor’s office.
Medicare Advantage (Part C) plans, which are private plans approved by Medicare, may also offer coverage for the shingles vaccine. These plans typically provide the same coverage as Part A, B, and D but may have additional benefits. If you have a Medicare Advantage plan, check with your plan provider to confirm the details of your coverage.
Private Health Insurance and Shingles Vaccination
Most private health insurance plans, including employer-sponsored plans and individual plans purchased through the Health Insurance Marketplace, generally cover the shingles vaccine. Under the Affordable Care Act (ACA), most health plans are required to cover preventive services at no cost to you, including vaccines recommended by the CDC.
The shingles vaccine is recommended for adults aged 50 and older, so if you fall into this category, your private insurance plan is likely to cover the cost of the vaccine. However, coverage can vary depending on your insurance provider and plan. Some insurance companies may cover the full cost of the vaccine, while others may require you to pay a portion of the cost, such as a deductible or copayment.
The cost of Shingrix can range from $150 to $200 per dose, and since the vaccine requires two doses, the total cost can be $300 to $400. Some insurance plans may cover both doses in full, while others may cover just one dose and leave you responsible for the remaining cost.
To find out whether your insurance covers the shingles vaccine and what your out-of-pocket costs will be, contact your insurance company. They can provide detailed information about your coverage, any applicable copays or coinsurance, and the best place to get the vaccine (such as a pharmacy or doctor’s office).
What to Do if Your Insurance Does Not Cover the Shingles Vaccine
If your insurance plan does not cover the shingles vaccine, you still have options. You may be able to pay for the vaccine out of pocket, but there are other ways to make the cost more affordable:
Check for manufacturer discounts: The makers of Shingrix, GlaxoSmithKline, may offer patient assistance programs or discounts for people who cannot afford the vaccine. Ask your doctor or pharmacist if any financial assistance is available.
Look for free or low-cost clinics: Some public health clinics or local health departments may offer vaccines at a reduced price or for free. Check with your local health department to see if they offer the shingles vaccine and whether any financial assistance is available.
Consider using a pharmacy discount card: Some pharmacies offer discount programs or savings cards that can lower the price of medications, including vaccines. Ask your pharmacist if any discounts are available.
Factors That Influence Coverage
Several factors can affect whether or not your insurance covers the shingles vaccine:
Age: Most insurance companies, including Medicare and private insurers, only cover the shingles vaccine for people aged 50 and older. If you are under 50, you may have to pay for the vaccine out of pocket.
Vaccine type: While Shingrix is the preferred vaccine, older vaccines like Zostavax may not be covered by all insurance plans. In some cases, your doctor may offer a choice between the two vaccines. Shingrix is preferred because it offers better protection, but check with your insurance provider to see if both options are covered.
Insurance plan specifics: The level of coverage you receive depends on the type of insurance plan you have. Some plans may have higher deductibles, copayments, or coinsurance, which can affect your out-of-pocket costs for the shingles vaccine.
What to Do Before Getting the Shingles Vaccine
Before you get the shingles vaccine, it’s important to:
Check with your insurance provider: Contact your insurance company to confirm whether the vaccine is covered, how much you’ll need to pay, and where you can get the vaccine.
Talk to your doctor: Your healthcare provider can help you determine if the shingles vaccine is right for you, especially if you have any health conditions that may affect your eligibility.
Plan for both doses: Remember that Shingrix requires two doses. Make sure to plan for both doses and confirm coverage for the second dose with your insurance provider.
Conclusion
The shingles vaccine is an important preventive measure, especially for older adults. Insurance coverage for the vaccine can vary depending on the type of insurance plan you have and your age. Medicare Part D, private health insurance plans, and many Medicare Advantage plans generally cover the cost of the vaccine. However, coverage details can vary, and you may be responsible for a portion of the cost, such as a copayment or coinsurance.
If your insurance does not cover the shingles vaccine, there are other options to make the vaccine more affordable, such as patient assistance programs, discount cards, and low-cost clinics. Before getting vaccinated, be sure to check with your insurance provider and healthcare provider to ensure you have the necessary information and coverage.
Taking the step to get vaccinated against shingles is an important way to protect your health and reduce the risk of complications.
Related topics:
