Shingles, also known as herpes zoster, is a condition you want to avoid. Thankfully, there is a vaccine that can decrease your risk for a shingles outbreak. You will want to know more about the Shingrix vaccine, where you can get it, and if your insurance will pay for it.
Shingles is a painful blistering rash that breaks out along the path of an infected nerve. The shingles virus can sometimes damage those nerve fibers causing pain that can last months, or even years, after the rash goes away. This is known as post-herpetic neuralgia.
The varicella-zoster virus causes chickenpox the first time you get it, but the virus does not go away when your symptoms do. Instead, it lies dormant in your body. As you get older or if your immune system gets weak, the virus can be reactivated, coming out as shingles.
It is estimated that 1 in 3 people will have a case of shingles in their lifetime. About half of cases occur in people 60 years and older.
This article will let you know how to find a Medicare plan that covers it and will give you other strategies to cut down on the cost when you don’t have one of these plans.
Shingrix is not the first shingles vaccine, but it is the only one currently on the market in the United States. Instead of using a live virus, the vaccine uses a protein from the virus to trigger an immune response. It is administered in two doses two to six months apart.
This shingles vaccine has been shown to decrease the risk for shingles by 97% for people between 50 and 69 years old and by 91% for people 70 and older. It reduces complications as well. The risk for post-herpetic neuralgia goes down by 91% and 89%, respectively, in those age groups.
Because the vaccine works well, it is important to know if and when Medicare covers it.
Medicare is a federally-funded healthcare program for people 65 and older and for people with qualifying disabilities. More than 61 million people were enrolled in Medicare as of 2020.
Medicare is broken down into four different parts. Part A and Part B are referred to as Original Medicare because they were the first parts written into law in 1965. The federal government runs these parts.
Unfortunately, Part A and Part B do not cover the shingles vaccine. You will have to turn to a Part C or Part D plan for that.
Unlike Original Medicare, Part C and Part D plans are run by private insurance companies. That said, these plans have to abide by standards that are set by the federal government.
Part C: Also known as Medicare Advantage, Part C plans cover everything that Part A and Part B do. The difference is they can also offer supplemental benefits for some services not covered by Original Medicare. These plans sometimes include a prescription drug benefit. When they do, they are known as MA-PD plans.
Part D: These plans offer coverage for your prescription medications, including several vaccines.
MA-PD plans and Part D plans are required to cover commercially available vaccines that are not covered by Original Medicare. That includes the Shingrix vaccine. However, what you pay may vary from plan to plan.
You can decide to be on Original Medicare or Medicare Advantage but not both. You can have a Part D plan with Original Medicare or with a Medicare Advantage plan that does not have prescription drug benefits.
GlaxoSmithKline reports that the average retail price for Shingrix is $162.01 per dose, $324.02 for the two-dose vaccine series. It could cost more depending on where you live.
When you receive a vaccine, your provider may charge an additional fee to administer it. This charge can sometimes be wrapped into your total vaccine cost. This may explain why the cost of the vaccine can sometimes be higher than the GlaxoSmithKline estimate.
Medicare Advantage plans with prescription drug coverage and Part D plans may cover the Shingrix vaccine, but that does not necessarily mean it will be free.
These plans put medications into different price categories known as tiers. The higher the tier, the more you pay. When you choose a plan, you may want to find one that has Shingrix on a low tier to keep your costs down.
Keep in mind you may also have to pay a copay or coinsurance when you get the vaccine. Also, if you did not yet pay your plan's deductible that year, you could end up paying more than your copay or coinsurance, or even full price, for the shot.
GlaxoSmithKline estimates that most people with Part D coverage, including those with MA-PD plans, pay less than $50 per dose.
You may be eligible for another health plan that covers Shingrix.
The Affordable Care Act (ACA) expanded coverage to include preventive services like the shingles vaccine. Anyone on a Health Insurance Marketplace plan (aka Obamacare plan) can get Shingrix without cost-sharing (e.g., deductibles, copays, and coinsurance) as long as they get their shot in network. The same applies to anyone on Medicaid in a state that expanded Medicaid.
According to GlaxoSmithKline, as many as 96% of private health plans cover the vaccine. On average, this costs beneficiaries less than $5 per dose.
If you do not have insurance coverage, you may have to pay the full price out of pocket.
If you are on Medicare, you cannot be on a Marketplace plan. You can, however, be on Medicaid. This is known as being dual eligible for Medicare and Medicaid.
Not having insurance does not mean you have to pay in full. In fact, even if you have insurance, you may be able to get a better deal.
GSK Patient Assistance Program for Vaccines: You may qualify for this program if you are 18 or older, live in the United States or Puerto Rico, and meet certain income criteria depending on the number of people living in your household.
The program is intended for people without insurance. It can also be used by anyone on Part D as long as they have already spent $600 on medications through their plan that year.
Prescription discount cards: There are many prescription discount cards that offer decreased rates for Shingrix. Consider looking into these programs to find a low rate in your area.
Popular cards include GoodRx and SingleCare, among others. It is important to know that these drug coupons cannot be used in conjunction with your Part D benefit. You will have to decide which will save you the most money.
Installment plans: Alternatively, you can reach out to your doctor’s office or local pharmacy to see if they have other financing options available. They may be willing to set up a payment plan to make the shingles vaccine more affordable for you.
The Centers for Disease Control and Prevention (CDC) recommends Shingrix vaccination for anyone 50 years and older, even if you have already had shingles, if you had another type of shingles vaccine, and if you don’t know whether or not you’ve had chickenpox in the past.
You should not get the vaccine if you are allergic to any of the components, are pregnant or breastfeeding, currently have shingles, or you have lab tests that definitively show that you do not have antibodies against the varicella-zoster virus. In that case, you may be better off getting the varicella (chickenpox) vaccine instead.
You have a choice on where to get vaccinated.
In your doctor’s office: You can get vaccinated in your doctor’s office. If the office is set up to bill Part D directly for your vaccination, you may only have to pay a copay at the time of your shingles shot. If not, you may have to pay all costs upfront and submit a claim to your Part D plan for reimbursement.
At your local pharmacy: You can go to your local pharmacy to get your shingles shot as long as they offer the vaccine and appropriately trained staff members administer it. The rules for pharmacy vaccination vary by state. You will likely need to pay for the vaccination upfront. Pharmacies are not legally required to dispense medications without payment.
Shingrix is an effective vaccine that can protect you against shingles outbreaks and complications like post-herpetic neuralgia. Medicare Part D plans cover this vaccine. So do Medicare Advantage plans that include a prescription drug benefit.
How much you pay will vary based on the plan you choose. On average, beneficiaries pay $50 per dose. If you cannot afford the vaccine, you may be able to apply for the GSK Patient Assistance Program or use a prescription discount card instead of your Part D benefit. You could also consider arranging an installment plan with your provider to spread out your payments.
Many Medicare plans offer partial coverage for the shingles vaccine. Check with your plan to make sure you know how much you could pay for Shingrix. This will give you a good starting point and help you figure out the best way to keep your costs down.
Although Medicare Part B covers some vaccines for free, the shingles vaccine is not one of them. In order to get your shingles vaccine covered by Medicare, you will need to enroll in a Medicare Advantage plan with prescription drug benefits (an MA-PD plan) or a stand-alone Part D prescription drug plan.
How much you pay will depend on the plan you choose, though it could be free in some instances. Deductibles and copays may apply.
Studies have shown that Shingrix has a long-lasting effect. One study in people 50 years and older found that the vaccine was 84% effective against shingles for at least seven years. Another study found that vaccinated people over 60 had immunity that lasted nine years. The effect was expected to last as long as 15 years.
Anyone who has had chickenpox in the past can get shingles. When you consider that 99% of people 40 years and older have had chickenpox (even if they don’t remember it), a large portion of the population is at risk.
That risk is even greater for people who have weak immune systems, but also in people who are 50 and older. People over age 60 account for half of cases even when they are not immunocompromised.
Whether you pay all at once for your vaccine depends on where you get it. When you get your vaccine at your doctor’s office, you may have to pay a copay upfront but can defer paying the rest until you receive your final bill.
When you get your shot at a local pharmacy, you may have to pay the full cost at the time of administration. In either case, your doctor’s office or pharmacy could potentially offer financing options or payment plans to spread your payments out over time.