One of our clients recently called us about her confusion with Medicare coverage of the shingles vaccine. Having both Original Medicare and Medigap Plan F, she expected to be fully covered. To her surprise, her cost was about $200. The post below (about Medicare coverage of vaccines in general and the shingles vaccine in particular) attempts to clarify the confusion.
Vaccines covered by Medicare Part B
Medicare Part B covers the three routine immunizations shown in the table below.
|Flu shots||Medicare generally covers flu shots once per flu season in the fall or winter. You pay nothing for getting the flu shot if a doctor or other qualified health care provider accepts the assignment for giving the shot.|
|Hepatitis B shots||Medicare covers these shots for people at high or medium risk for Hepatitis B. You pay nothing for the shot if a doctor or other qualified health care provider accepts assignment.|
|Pneumococcal shot||Medicare covers pneumococcal shots to help prevent pneumococcal infections (like certain types of pneumonia). Most people only need this shot once in their lifetime. Talk with your doctor or other health care provider to see if you should get this shot. You pay nothing if a doctor or other qualified health care provider accepts assignment for giving the shot.|
With Original Medicare, Part B yearly deductible, as well as coinsurance/copayment, are not applied to the vaccines or their administration. In other words, they are free for you. The rules are the same for Medicare Advantage plans except that the Hepatitis B vaccine may be subject to a Part B deductible.
Other immunizations are covered by Part B only if there has been direct exposure to a dangerous disease with a significant risk of contracting this disease. The coverage applies to:
- Hepatitis A
- Immune Globulins
- Rabies prophylaxis
- Tetanus and diphtheria toxoids
- Tetanus toxoid
Vaccines covered by Medicare Part D (including Shingles Vaccination)
According to Medicare regulations, ALL commercially available vaccines other than vaccines covered by Part B (i.e., flu, hepatitis B, and pneumonia) must be on formularies for all Medicare Part D plans. The shingles vaccine is one of the vaccines covered by all Medicare Part D plans.
Part D will cover not only the vaccination itself but also its administration by a doctor or pharmacist. Check any restrictions applied to your Part D plan in order to find the most cost-effective solution. These may include pharmacy selection, required copayment / coinsurance, etc.
Shingles Vaccine and its economics
Shingles is a painful, blistering skin rash caused by the varicella-zoster virus, the same virus that causes chicken pox. The National Library of Medicine says the following about shingles:
After you get chickenpox, the shingles virus remains inactive (becomes dormant) in certain nerves in the body. Shingles occur after the virus becomes active again in these nerves years later.
Two popular shingles vaccines are Zostavax and Varivax. Most Medicare Part D plans will cover at least one of them, but you should check your plan formulary to be certain.
The typical full price for the shingles vaccine Zostavax is a $180, and for Varivax the cost is $100. Part D copays for the shingles vaccination vary for different Part D plans. The typical copay is about $50.
To find the most cost-effective way to cover your shingles vaccine, follow the steps below:
- Contact Part D plan to find your copay for your shingles vaccination
- Make sure that the pharmacy where you plan to make your vaccination IS on your plan network. Otherwise, instead of reasonable copay, you may find yourself paying the full price.
- If you get the vaccination in a doctor’s office, make sure the doctor can bill your Plan D directly or work through a pharmacy in your plan network. Otherwise, you may end up paying the full price yourself.
- Finally, if a copayment in your Part D plan is too high, consider changing the plan.
US Government Sources
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