Shingrix is a vaccine used to prevent shingles, a painful condition caused by the varicella-zoster virus (the same virus that causes chickenpox). As a preventative measure, it is often recommended for adults 50 and older, or those who have weakened immune systems. But the question many people have is whether insurance will cover the cost of Shingrix. This article will break down everything you need to know about insurance coverage for the Shingrix vaccine, including factors that affect whether or not your insurance will pay for it.
What Is Shingrix?
Shingrix is a vaccine that helps protect adults against shingles. Shingles can cause a painful rash, and sometimes nerve pain that can last for months or even years. The vaccine is given in two doses, typically two to six months apart. It is recommended for adults 50 and older, even if they have had shingles in the past or received the older chickenpox vaccine (Zostavax).
Shingrix has been shown to be highly effective, providing protection against shingles for up to four years. It’s also recommended for those who are immunocompromised, as they are at higher risk of developing severe complications from shingles.
Why Is Shingrix Important?
Shingles can be a serious illness, especially for older adults. While the rash usually goes away in a few weeks, the pain can be long-lasting. This condition, called post-herpetic neuralgia, can cause severe nerve pain that persists long after the rash heals. In some cases, shingles can lead to complications like eye infections, hearing loss, and even stroke. The vaccine helps to reduce the risk of developing shingles and its complications.
How Much Does Shingrix Cost?
The cost of Shingrix can vary depending on where you get the vaccine and your location. On average, each dose of Shingrix costs between $150 and $200. Since the vaccine requires two doses, the total cost can be $300 to $400.
Some people may be able to use insurance to reduce the cost, while others may need to pay out-of-pocket. Insurance plans vary widely, so it’s important to understand what coverage options you have.
Does Insurance Cover Shingrix?
Most insurance plans, including Medicare and private health insurance, will cover the cost of Shingrix, but there are some important factors to consider. The type of insurance you have, your plan’s specific coverage, and your pharmacy’s policies can all affect how much you pay out-of-pocket.
Medicare and Shingrix
For Medicare recipients, Shingrix is typically covered under Medicare Part D, which is the prescription drug plan. However, there are a few things to keep in mind:
Medicare Part D Coverage: If you have a Medicare Part D plan, you should check whether Shingrix is included in your plan’s formulary. Most Part D plans cover Shingrix, but coverage may vary by plan.
Cost of the Vaccine: Even though Shingrix is covered, the amount you will pay depends on your Part D plan’s co-payment, deductible, and any other out-of-pocket costs. Some plans may cover the full cost after your deductible, while others may require you to pay a percentage of the cost.
Medicare Advantage Plans: If you have a Medicare Advantage plan (Part C), the coverage for Shingrix may vary. Most Advantage plans include prescription drug coverage, so it’s likely that Shingrix will be covered. However, you will still need to check with your plan to confirm coverage and cost.
No Out-of-Pocket Cost for Some: If your Part D plan covers Shingrix and you have already met your deductible, you may only have to pay a co-payment or coinsurance. In some cases, if you have “Extra Help” (a program that helps low-income seniors with prescription drug costs), the cost may be reduced or eliminated altogether.
Private Health Insurance and Shingrix
For those with private health insurance, the coverage for Shingrix will depend on your individual plan. Many private insurers cover the vaccine, but coverage may be subject to the following factors:
Health Insurance Marketplace Plans: If you get your insurance through the Health Insurance Marketplace, most plans are required to cover preventive services like Shingrix without charging a deductible or copay. This means that if the vaccine is recommended by your doctor, it should be covered at no extra cost. However, some plans may charge you for the vaccine if it is considered a “non-preventive” service.
Employer-Sponsored Plans: If you have health insurance through your employer, Shingrix may be covered as part of your plan’s preventive care services. Preventive services are typically covered without any out-of-pocket costs, but again, this depends on the specifics of your plan.
Co-pays and Deductibles: While many private health insurance plans cover Shingrix, you may still be required to pay a co-payment or deductible. Some plans may require you to pay a portion of the cost of the vaccine, especially if it’s administered at a doctor’s office rather than a pharmacy.
Pharmacy Benefits: If your insurance plan covers prescriptions, you might be able to get Shingrix at a pharmacy for a lower cost. In some cases, pharmacies may have discounts or reduced prices for patients who are covered by private insurance.
How to Find Out If Your Insurance Covers Shingrix
If you’re unsure whether your insurance covers Shingrix, there are a few steps you can take to find out:
Call Your Insurance Provider: The best way to confirm coverage is to call your insurance provider directly. They can tell you whether Shingrix is covered, what the co-pay or deductible might be, and where you can get the vaccine.
Check Your Plan’s Formulary: If you have a private insurance plan, your insurance provider should have a formulary (a list of covered drugs) available online. Shingrix should be listed in the vaccine section, but it’s always a good idea to double-check.
Talk to Your Doctor: Your doctor or healthcare provider can help you understand your coverage. They may also be able to direct you to a pharmacy or clinic that accepts your insurance and has the vaccine in stock.
Pharmacy Resources: Many pharmacies, including chains like Walgreens, CVS, and Rite Aid, can help you find out whether your insurance covers Shingrix. Pharmacists are often familiar with insurance billing codes and can let you know how much you’ll need to pay out-of-pocket.
What Happens If Your Insurance Doesn’t Cover Shingrix?
If your insurance doesn’t cover Shingrix, you will need to pay the full price of the vaccine. However, there are some options to help reduce the cost:
Patient Assistance Programs: Some pharmaceutical companies, including the makers of Shingrix, offer patient assistance programs that provide financial help or discounts for those who are uninsured or underinsured. You can ask your doctor or pharmacist about these programs.
Look for Discounts: Some pharmacies offer discounts for uninsured or underinsured patients. Websites like GoodRx allow you to compare prices for Shingrix at different pharmacies and find the best deal.
Paying Out-of-Pocket: If you must pay out-of-pocket, you may also be able to use a Health Savings Account (HSA) or Flexible Spending Account (FSA) to cover the cost. These accounts allow you to use pre-tax money for medical expenses, including vaccines.
Conclusion
In most cases, Shingrix is covered by insurance, whether through Medicare, private health insurance, or employer-sponsored plans. However, coverage details can vary depending on your specific insurance plan, your deductible, co-pays, and the pharmacy or doctor administering the vaccine. To find out exactly what your insurance covers, contact your provider directly, check your plan’s formulary, or speak with your doctor or pharmacist.
Getting vaccinated against shingles with Shingrix can help protect you from a painful and potentially debilitating condition, and understanding your insurance options can make the process more affordable.
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