The risk of developing shingles, a painful rash caused by the varicella-zoster virus, increases significantly with age. The recommended vaccine, Shingrix, requires a two-dose series for adults aged 50 and older. Understanding Medicare coverage for this preventive measure can be confusing, as different parts cover different services. Medicare generally covers the Shingles vaccine, but coverage depends entirely on enrollment in the correct prescription drug plan.
Understanding Shingles Vaccine Coverage Under Medicare
The Shingles vaccine is classified as a preventive prescription drug, meaning its coverage falls under Medicare Part D. Original Medicare (Parts A and B) does not pay for the Shingrix vaccine itself.
Vaccine coverage is typically split between Medicare parts based on the type of immunization. Medicare Part B covers certain preventive shots, such as the annual influenza, pneumonia, and COVID-19 vaccines. However, because Shingrix is administered as a prescription drug, it is covered exclusively under Part D.
To ensure coverage, you must be enrolled in a Medicare Part D prescription drug plan. This coverage can come from a stand-alone Part D plan or a Medicare Advantage plan (Part C) that includes prescription drug benefits. If you only have Original Medicare without separate Part D coverage, you will be responsible for the full cost of the two-dose series.
Medicare Part D plans are required to cover all adult vaccines recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP), which includes Shingrix. This requirement ensures that access to the vaccine is standardized across all Part D plans nationwide.
How Your Medicare Plan Affects Out-of-Pocket Costs
A major change in federal law has significantly simplified the financial reality of getting the Shingles vaccine for Medicare beneficiaries. The Inflation Reduction Act (IRA) of 2022 eliminated all out-of-pocket costs for ACIP-recommended vaccines covered by Part D. This change became effective at the start of 2023.
This means that if you have any form of Medicare Part D coverage, you will pay a flat $0 for the Shingles vaccine. This zero-cost mandate applies to the vaccine itself, the administration fee, and any dispensing fees. You are not subject to any deductible, copayment, or coinsurance for the Shingrix vaccine, regardless of which coverage phase your Part D plan is currently in.
Prior to this legislative change, beneficiaries often faced varying out-of-pocket costs, which created a financial barrier for many. The IRA removed this barrier entirely for the two-dose series of Shingrix.
For those without Part D coverage, the cost of the vaccine remains high, often exceeding $180 per dose. The current $0 cost for Part D enrollees provides a financial incentive to ensure enrollment in a prescription drug plan.
Where to Get the Shingles Vaccine
The location where you receive the Shingles vaccine is important for ensuring proper coverage under your Part D plan. The vaccine is typically administered at a participating pharmacy, which is the most streamlined way to use your Part D benefits. Most Medicare Part D enrollees obtain their Shingles vaccine this way, as pharmacies are set up to bill Part D directly for the drug and the administration fee.
Receiving the vaccine at a doctor’s office or clinic may lead to complications with billing and could result in higher initial out-of-pocket costs. Many physician offices are not equipped to bill Medicare Part D directly, as Part D networks are defined primarily by pharmacy networks. In such cases, you might be required to pay the full cost upfront and then submit a claim to your Part D plan for reimbursement, which can be a lengthy process.
Before getting the shot, it is always recommended to confirm that the pharmacy or provider is within your Part D plan’s network to avoid any unexpected billing issues. Utilizing an in-network pharmacy ensures the process is seamless.