Shingles, also known as herpes zoster, is a viral infection that causes painful rashes and blisters. It is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. The risk of developing shingles increases as you age, with people aged 50 and older being more susceptible. To prevent this painful condition, the Centers for Disease Control and Prevention (CDC) recommends the Shingrix vaccine. But for those who are eligible for Medicare, the question remains: Is the cost of Shingrix covered by Medicare?
This article will explain everything you need to know about Medicare coverage for the Shingrix vaccine, including which parts of Medicare provide coverage, out-of-pocket costs, and other important factors to consider when deciding to get vaccinated.
What is Shingrix?
Shingrix is a vaccine developed to prevent shingles. It is a recombinant vaccine, which means it uses pieces of the virus to stimulate the immune system without using the live virus itself. Shingrix has been proven to be highly effective in reducing the risk of shingles and its associated complications, such as postherpetic neuralgia (PHN), a condition that causes long-term pain after the shingles rash has healed.
Unlike the older Zostavax vaccine, which was made from a weakened version of the live virus, Shingrix has been shown to offer stronger and longer-lasting protection, especially in older adults.
The vaccine is administered in two doses. The first dose is given, followed by the second dose two to six months later. Both doses are necessary for full protection.
Medicare Coverage for Shingrix
Medicare is a federal health insurance program primarily for people aged 65 or older, though some younger people with disabilities may also qualify. Medicare consists of different parts, and coverage for vaccines like Shingrix depends on which part of Medicare you have. To determine whether Shingrix is covered under your Medicare plan, it is essential to understand how the program works.
Medicare Part B (Medical Insurance)
Medicare Part B generally covers medically necessary services, including outpatient care, doctor visits, certain preventive services, and some vaccines. Unfortunately, Shingrix is not covered under Part B for everyone.
Medicare Part B does cover vaccines like the flu vaccine, the pneumococcal vaccine, and the hepatitis B vaccine, but it does not routinely cover vaccines for shingles. Shingrix is considered a preventive vaccine and is not classified as a medically necessary vaccine under Medicare Part B. Therefore, if you are receiving Shingrix as a preventive measure, it may not be covered under Part B.
Medicare Part D (Prescription Drug Coverage)
Medicare Part D provides prescription drug coverage, which includes coverage for many vaccines that are not covered under Medicare Part B, including Shingrix. Part D plans are offered by private insurance companies approved by Medicare. These plans cover prescription medications, including vaccines, but you must check if your plan covers Shingrix specifically.
Medicare Part D is often the best option for covering the cost of the Shingrix vaccine. Most Part D plans cover vaccines like Shingrix, but coverage can vary from plan to plan. It is important to contact your Part D provider to confirm that Shingrix is included in your plan’s coverage and to learn about the costs involved.
Medicare Advantage (Part C) Plans
Medicare Advantage, or Part C, is an alternative to traditional Medicare that is offered by private insurance companies. These plans must provide the same benefits as Medicare Parts A and B, but they often offer additional coverage and benefits, including prescription drug coverage (Part D).
If you have a Medicare Advantage plan with prescription drug coverage, your plan may cover the cost of Shingrix. Like Medicare Part D, coverage for Shingrix under Medicare Advantage plans can vary. Some plans may have additional benefits or cost-saving options for preventive vaccines like Shingrix.
You should contact your Medicare Advantage plan provider to verify if Shingrix is covered, and ask about any associated costs. If your plan includes prescription drug coverage, it will likely provide coverage for Shingrix as part of its medication benefits.
Costs of Shingrix with Medicare
Even if you are eligible for coverage of Shingrix under Medicare Part D or a Medicare Advantage plan, there are still out-of-pocket costs to consider. The costs of Shingrix can vary based on several factors, including the type of Medicare plan you have, where you receive the vaccine, and whether you have reached your plan’s deductible.
Medicare Part D Costs
If you are covered under a Medicare Part D plan, you may have to pay a deductible, co-pay, or coinsurance for the Shingrix vaccine. The cost of the vaccine can range from around $150 to $200 per dose. Since you need two doses of Shingrix for full protection, the total cost can be approximately $300 to $400.
The exact amount you will pay depends on your specific Part D plan. Some plans may cover the vaccine in full, while others may require you to pay a co-payment or coinsurance. Additionally, if you have not yet met your plan’s annual deductible, you may have to pay the full cost of the vaccine until the deductible is met.
Once your deductible is met, you will likely only need to pay a portion of the cost, such as a co-pay or a coinsurance percentage. The amount of this co-pay or coinsurance can vary depending on your plan’s formulary and coverage.
Medicare Advantage (Part C) Costs
If you have Medicare Advantage with prescription drug coverage, the costs for Shingrix are generally similar to Medicare Part D. However, because Medicare Advantage plans are offered by private insurers, the exact costs can vary widely. You may need to pay a co-pay, coinsurance, or the full cost of the vaccine until your deductible is met.
In many cases, Medicare Advantage plans will have lower co-pays or additional benefits that may help reduce your out-of-pocket costs. It is essential to check with your Medicare Advantage provider for detailed cost information and coverage specifics for Shingrix.
Other Factors That Affect the Cost of Shingrix
Pharmacy Location: Where you receive the Shingrix vaccine can impact the cost. Vaccines administered in a doctor’s office, pharmacy, or other outpatient settings may have different costs. It is important to shop around and check with different pharmacies or healthcare providers to find the most cost-effective option for getting the vaccine.
Annual Deductibles: Some Medicare Part D and Medicare Advantage plans may have annual deductibles that must be met before your insurance begins to cover the vaccine. This deductible can range from a few hundred dollars to over a thousand dollars, depending on your plan.
Vaccination Schedule: Since Shingrix is administered in two doses, it is important to ensure that both doses are covered by your Medicare plan. Be sure to check with your insurer to verify that both doses are covered under the same terms, as some plans may treat the second dose differently.
Can You Get Shingrix Without Medicare?
If you are not yet eligible for Medicare or do not have prescription drug coverage, you may still be able to get Shingrix through other means. Some private insurance plans may cover the cost of the vaccine, or you may be able to purchase the vaccine out-of-pocket. In some cases, the vaccine may be offered at a discounted rate through certain healthcare programs, such as those provided by local health departments or community health centers.
The cost of Shingrix without insurance can be quite high, but some drug manufacturers may offer assistance programs for eligible individuals, reducing the out-of-pocket cost of the vaccine.
Conclusion
Shingrix is a highly effective vaccine for preventing shingles, and it is recommended for adults aged 50 and older. For those who have Medicare, the cost of the Shingrix vaccine may be covered under Medicare Part D or a Medicare Advantage plan with prescription drug coverage. However, Medicare Part B does not generally cover Shingrix, as it is considered a preventive vaccine.
Out-of-pocket costs for Shingrix can vary depending on your Medicare plan, and it is essential to contact your plan provider to verify coverage and understand your financial responsibility. Remember, the vaccine is given in two doses, so be sure to confirm that both doses are covered.
If you are eligible for Medicare, getting the Shingrix vaccine may help you avoid the pain and complications of shingles. Be sure to talk to your doctor about getting vaccinated and explore your options for coverage through Medicare or other programs to ensure you get the vaccine at the best possible cost.
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