Many people are surprised to learn that Medicare coverage for the shingles vaccine works differently than coverage for a flu shot or many other preventive services.
The shingles vaccine, commonly called Shingrix, is generally covered through Medicare Part D, which is prescription drug coverage. That means the details of your coverage can depend on the drug plan you choose and the pharmacy or provider you use.
Understanding this before you schedule your vaccine may help you avoid confusion at the pharmacy counter or doctor’s office.
What is shingles, and why does the vaccine matter?
Shingles is a painful rash caused by the same virus that causes chickenpox. After a person has chickenpox, the virus can remain inactive in the body for many years. It can become active again later in life and cause shingles.
Shingles may cause a painful rash, burning, itching, or blisters. Some people can have nerve pain that lasts after the rash has gone away. The risk of shingles generally increases with age.
The shingles vaccine may lower the chance of getting shingles and may reduce the risk of serious complications. Your doctor or pharmacist can help you decide whether it is appropriate for you based on your health history.
Which part of Medicare covers the shingles vaccine?
Medicare Part D generally covers the shingles vaccine. Part D is available through stand-alone prescription drug plans and through many Medicare Advantage plans that include prescription drug coverage.
Original Medicare includes Part A and Part B. Part B covers certain vaccines, including flu, pneumonia, COVID-19, and hepatitis B vaccines in situations where Medicare’s coverage rules are met. However, Part B does not generally cover the shingles vaccine.
This distinction is important. A person with Original Medicare who does not have Part D may not have routine Medicare coverage for Shingrix. A person enrolled in a Medicare Advantage plan should check whether the plan includes Part D drug coverage and how the plan handles vaccines.
Will you pay anything for the shingles shot with Medicare?
Under current Medicare Part D rules, recommended adult vaccines, including the shingles vaccine, are generally covered with no deductible or copayment when the plan’s coverage requirements are followed.
Still, it is wise to confirm the details before receiving the vaccine. Plans may have network pharmacy rules or other steps that affect how the claim is processed. Benefits can also vary by plan, carrier, and state.
Ask the pharmacy to bill your Part D plan before you receive the shot. This may help you know whether the vaccine is covered at that location and whether there is anything you need to do first.
Do you need two shingles vaccine doses?
Shingrix is commonly given as a series of two doses. The timing between doses can depend on your health situation and guidance from your medical provider.
It is important to receive both doses if your provider recommends the full series. Getting only the first shot may not provide the same level of protection as completing the series.
Because coverage rules can change, confirm that both doses will be billed through your Part D plan. You may also want to use the same in-network pharmacy for each dose when possible.
Where can you get the shingles vaccine?
Many people receive the shingles vaccine at a retail pharmacy. Some doctor’s offices, clinics, and other health care settings may also offer it.
A pharmacy may be the simplest option because pharmacies routinely bill Part D plans for vaccines. If you receive the vaccine at a doctor’s office, ask in advance whether the office can bill your Part D plan directly. If it cannot, you may need to pay first and submit paperwork for possible reimbursement.
That does not necessarily mean the vaccine will not be covered. It simply means the billing process may be less convenient.
What should you ask your plan or pharmacy?
A quick call can help you avoid surprises. Consider asking these questions:
- Is Shingrix covered under my Medicare Part D plan?
- Is this pharmacy or provider in my plan’s network?
- Will the pharmacy bill my Part D plan directly?
- Do I need to use a preferred pharmacy?
- Is there anything I need to bring besides my Medicare card and plan card?
- Will the second dose be covered under the same process?
Keep your Part D or Medicare Advantage plan card with you. The pharmacy usually needs the information on that card rather than only your red, white, and blue Medicare card.
What if you do not have Part D coverage?
If you have Original Medicare without Part D, you may want to review your options carefully. You generally cannot enroll in a Part D plan at any time of year. Enrollment opportunities often depend on your circumstances and Medicare’s enrollment periods.
People with Medicare Advantage should also be careful before making any change. Medicare Advantage plans can include medical and drug coverage together, and changing plans may affect doctors, hospitals, prescription coverage, and other benefits.
The shingles vaccine is only one part of choosing Medicare coverage. It can be helpful to look at your medications, preferred pharmacies, doctors, travel needs, and comfort with out-of-pocket costs as well.
Does a Medicare Supplement cover the shingles vaccine?
Medicare Supplement insurance, also called Medigap, helps pay certain out-of-pocket costs left by Original Medicare Parts A and B. Because the shingles vaccine is generally covered under Part D rather than Part A or Part B, a Medicare Supplement plan does not usually pay for it.
People with Original Medicare and a Medicare Supplement typically still need a separate Part D plan for prescription drug coverage, including coverage for vaccines such as Shingrix.
Medicare choices can feel complicated, especially when different parts of Medicare cover different services. If you would like free, no-pressure help understanding how Medicare Supplement and Part D coverage may fit together, reach out to Eric for guidance based on your situation.