Shingles (Herpes Zoster) is a painful rash caused by the reactivation of the varicella-zoster virus. Since the virus remains dormant in the body, the risk of developing Shingles increases significantly with age. For individuals enrolled in Medicare, coverage for the preventive vaccine and treatment involves multiple, distinct parts of the Medicare program.
Coverage for the Shingles Vaccine Under Medicare Part D
The Shingrix vaccine is covered exclusively under Medicare Part D, the prescription drug benefit. Original Medicare (Parts A and B) specifically excludes coverage for the Shingles vaccine. A beneficiary must be enrolled in a Part D prescription drug plan—either stand-alone or bundled within a Medicare Advantage plan—to receive coverage.
Since January 1, 2023, the Inflation Reduction Act eliminated all out-of-pocket costs for adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), including Shingrix. Beneficiaries with Part D coverage pay zero dollars for the vaccine and its administration fee, regardless of meeting their plan’s deductible. The vaccine is administered as a two-dose series, typically given two to six months apart, and both are covered at no cost. Receiving the vaccine at an in-network pharmacy is recommended, as they can bill Part D directly, ensuring the zero-dollar cost-share.
Coverage for Shingles Treatment Under Original Medicare
If a person develops an active case of Shingles, the required medical care falls under Original Medicare, Parts A and B. Outpatient services, such as doctor visits and diagnostic tests, are covered under Medicare Part B. After the annual Part B deductible is met, Medicare pays 80% of the approved amount, and the beneficiary is responsible for the remaining 20% coinsurance.
Treatment primarily involves antiviral medications, such as Acyclovir, Valacyclovir, or Famciclovir, which work best when started soon after the rash appears. These retail prescription drugs are covered under the beneficiary’s Medicare Part D plan, subject to the plan’s specific cost-sharing structure. If complications, such as a severe infection or postherpetic neuralgia, require an inpatient hospital stay, the associated costs are covered under Medicare Part A.
Shingles Coverage Through Medicare Advantage Plans
Medicare Advantage plans (Part C) are offered by private insurance companies approved by Medicare and must cover all the benefits of Original Medicare (Parts A and B). Most Medicare Advantage plans include prescription drug coverage (MAPD), integrating the Part D benefit for both the vaccine and antiviral treatment. This bundling simplifies coverage, as both preventive and treatment costs are managed by a single plan.
While Part C plans must adhere to the $0 cost for the Shingles vaccine, their cost-sharing for treatment services differs from Original Medicare. These plans often utilize fixed copayments for doctor visits and hospital stays, rather than the Part B 20% coinsurance model. Medicare Advantage plans operate with provider networks (HMOs or PPOs); seeking care outside the network may result in higher out-of-pocket costs.
Beneficiary Costs and Financial Considerations
Despite comprehensive coverage, beneficiaries still face potential out-of-pocket expenses related to Shingles treatment. For those with Original Medicare, the primary financial burden for an active infection includes the Part B annual deductible and the 20% coinsurance for covered Part B services. Inpatient hospital stays under Part A also involve a deductible per benefit period.
The cost of antiviral prescription medications under Part D varies based on the plan’s formulary and tier structure. Generic options like Acyclovir are typically placed on a lower, less expensive tier. Many beneficiaries purchase a Medigap policy to help cover Part A and Part B deductibles and coinsurance. However, a separate Part D plan is required for vaccine and retail antiviral coverage, as Medigap policies do not include prescription drug coverage.