Shingles is a painful condition caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. Shingrix, a vaccine used to prevent shingles and its complications, has gained popularity due to its effectiveness. If you are on Medicare and are considering getting the Shingrix vaccine, you might wonder whether Medicare Part B covers this cost. This article will clarify the role of Medicare Part B in covering Shingrix and explore alternative coverage options.
Understanding Medicare Part B
Medicare is a federal health insurance program primarily designed for people aged 65 and older, as well as some younger individuals with certain disabilities. Medicare has four main parts:
- Part A: Covers inpatient hospital care, skilled nursing facilities, and some home health care.
- Part B: Covers outpatient care, doctor visits, preventive services, and certain medical supplies.
- Part C: Medicare Advantage plans offered by private companies that include Part A, Part B, and sometimes Part D benefits.
- Part D: Covers prescription drugs.
Medicare Part B specifically focuses on outpatient services and preventive care. However, not all preventive services, like vaccines, fall under its coverage.
What Is Shingrix?
Shingrix is a vaccine used to prevent shingles and postherpetic neuralgia (PHN), a common complication of shingles. Approved by the FDA in 2017, Shingrix is highly effective, with studies showing it prevents shingles in over 90% of individuals aged 50 and older.
Unlike older shingles vaccines, Shingrix is a recombinant vaccine, meaning it uses a non-live component of the virus. It is administered in two doses, with the second dose given two to six months after the first. Shingrix is recommended for:
- Adults aged 50 and older.
- Adults aged 19 and older with weakened immune systems.
Does Medicare Part B Cover Shingrix?
Medicare Part B generally does not cover the Shingrix vaccine. Part B covers vaccines like:
- Influenza (flu) vaccine.
- Pneumococcal vaccine.
- Hepatitis B vaccine for high-risk individuals.
- Vaccines directly related to treatment after an injury or exposure, like tetanus.
Since Shingrix is not directly tied to immediate medical treatment or exposure, it does not qualify for coverage under Part B.
How Can You Get Shingrix Covered Under Medicare?
Although Medicare Part B does not cover Shingrix, there are other ways to have the vaccine covered:
Medicare Part D
Medicare Part D is the portion of Medicare that provides prescription drug coverage, including most vaccines not covered by Part B. Many Part D plans fully or partially cover the Shingrix vaccine. To utilize this coverage:
- Check your Part D plan’s formulary to confirm Shingrix is included.
- Confirm if your preferred pharmacy is in-network for your plan.
- Be aware of any copayments, coinsurance, or deductibles associated with the vaccine.
Medicare Advantage Plans
Some Medicare Advantage plans (Part C) include prescription drug coverage. If your Medicare Advantage plan includes drug coverage, it is likely to cover Shingrix, just as a standalone Part D plan would. Review your plan’s specifics to ensure Shingrix is covered and confirm any out-of-pocket costs.
Cost of Shingrix Without Coverage
If you do not have Medicare Part D or other insurance coverage, you will need to pay out-of-pocket for Shingrix. The price can vary depending on the pharmacy, but the average cost is about $150 to $200 per dose. Since Shingrix requires two doses, the total cost can range from $300 to $400.
Some pharmacies or clinics may offer discounts or payment plans for individuals paying out-of-pocket. Comparing prices at different locations may help reduce costs.
Where Can You Get Shingrix?
Shingrix is widely available at:
- Pharmacies like CVS, Walgreens, and Walmart.
- Doctor’s offices.
- Community health clinics.
If you are using Medicare Part D, it is essential to check whether the location is within your plan’s network. Some pharmacies may also offer special programs or deals to help reduce vaccine costs.
Why Should You Consider Shingrix?
Shingles is a serious condition that can lead to severe complications. The most common complication, postherpetic neuralgia, causes long-term nerve pain that can last months or even years after the shingles rash resolves. Other complications include:
- Vision problems if shingles affects the eyes.
- Bacterial infections of the skin.
- Neurological issues like hearing loss or encephalitis.
Shingrix provides a high level of protection against shingles and its complications. The vaccine is especially important for older adults and those with weakened immune systems, as they are at higher risk of severe shingles outcomes.
Steps to Get Shingrix Through Medicare
To ensure a smooth process when getting Shingrix, follow these steps:
Review Your Medicare Plan: Determine if you have Part D or a Medicare Advantage plan that includes prescription drug coverage.
Check Coverage Details: Contact your plan provider to confirm if Shingrix is covered and understand your out-of-pocket costs.
Locate a Pharmacy: Find an in-network pharmacy that administers the Shingrix vaccine.
Schedule Both Doses: Remember to schedule the second dose within two to six months of the first dose.
Additional Financial Assistance
If you have difficulty affording Shingrix, consider these options:
Pharmaceutical Assistance Programs: Some vaccine manufacturers offer programs to help reduce costs. The GSK Patient Assistance Program may provide Shingrix at a reduced cost or for free to eligible individuals.
State Health Departments: Some states have vaccination programs for uninsured or underinsured adults.
Nonprofit Organizations: Groups like the Patient Advocate Foundation may offer financial support for vaccine costs.
Final Thoughts
While Medicare Part B does not cover Shingrix, Medicare Part D and many Medicare Advantage plans do. If you are eligible for Medicare, it is crucial to understand your specific plan’s coverage details to avoid unexpected costs. Shingrix is a valuable vaccine that can protect you from the pain and complications of shingles, making it a worthwhile investment in your health.
Take the time to explore your coverage options and consult with your healthcare provider to ensure you are protected against shingles. Your health and peace of mind are worth it.
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