Get Your Free Guide to Medicare Shingles Vaccine Coverage

Understanding Medicare Coverage for Shingles Vaccination

Medicare provides coverage for shingles vaccines as part of its preventive care benefits. Shingles, also called herpes zoster, is a viral infection that causes a painful rash. It develops in people who have previously had chickenpox, as the virus can reactivate years or decades later. According to the Centers for Disease Control and Prevention (CDC), about 1 in 3 Americans will develop shingles during their lifetime, and the risk increases significantly after age 50.

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The shingles vaccine is recommended for adults age 50 and older, regardless of whether they remember having chickenpox. Two vaccines are currently available: Shingrix (recombinant zoster vaccine) and Zostavax (live attenuated zoster vaccine). Shingrix is the newer vaccine and is preferred by health officials because it provides stronger protection. Clinical trials showed Shingrix was about 90% effective at preventing shingles and post-herpetic neuralgia, a serious complication causing long-term nerve pain.

Medicare Part B covers both vaccines, though coverage rules differ between them. Part B is the portion of Original Medicare that covers doctor visits, outpatient services, and preventive care. When you receive the vaccine at a Medicare-approved provider, you typically pay nothing out of pocket if the provider bills Medicare correctly. However, some situations may result in costs to you, depending on your specific coverage plan and where you receive the vaccine.

Understanding how Medicare covers these vaccines helps you make informed decisions about your healthcare. This guide provides information about what Medicare covers, how the coverage works, and what to expect when you decide to get vaccinated. The information here can help you understand your options and prepare for conversations with your healthcare provider.

Practical Takeaway: Shingles vaccination is a preventive service covered by Medicare Part B for adults age 50 and older. Knowing that coverage exists is the first step in learning more about whether vaccination might be right for you.

How Medicare Part B Covers Shingles Vaccines

Medicare Part B covers the cost of shingles vaccines under its preventive services benefit. This means that when you receive the vaccine from a Medicare-approved provider, Medicare pays for the vaccine itself. The vaccine is considered a covered preventive service, similar to flu shots and pneumonia vaccines that Medicare also covers.

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Shingrix requires two doses given 2 to 6 months apart. Both doses are covered by Medicare Part B. When you go for your first dose, Medicare covers the cost of the vaccine. When you return for your second dose, Medicare again covers that vaccine's cost. The spacing between doses matters for effectiveness—the CDC recommends waiting at least 2 months between doses, though spacing them 6 months apart is also acceptable.

The coverage works through a few different pathways depending on where you receive the vaccine. If you get the vaccine at your doctor's office, the office bills Medicare directly for the vaccine. If you receive it at a pharmacy, the pharmacy bills Medicare. If you're in a hospital outpatient setting, the hospital bills Medicare. In most cases, when billed correctly to Medicare, you should not owe anything for the vaccine itself.

However, you may have other costs depending on your situation. If you have Original Medicare (Part A and Part B), you typically have no cost for the vaccine. But if you have a Medicare Advantage plan (Part C), your out-of-pocket costs may vary. Some Medicare Advantage plans charge a copay for vaccines, while others cover them at no cost. You should check your specific plan's documents or contact your plan to understand what you might owe.

Some people have both Medicare and other insurance, like employer coverage or Medicaid. In these cases, coordination of benefits rules determine which insurance pays first. Generally, Medicare is the primary payer for people age 65 and older, meaning Medicare covers the vaccine first.

Practical Takeaway: Contact your Medicare plan before scheduling a vaccine appointment to learn your exact out-of-pocket cost. Call the number on your Medicare card or visit Medicare.gov to find your plan's coverage details.

Differences Between Shingrix and Zostavax

Two shingles vaccines are currently available in the United States: Shingrix and Zostavax. Understanding the differences between them helps explain why Medicare coverage policies treat them differently and why one is now preferred.

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Shingrix is a recombinant vaccine, meaning it's made using pieces of the virus created in a laboratory rather than the live virus itself. It was approved by the FDA in 2017 and is now the preferred shingles vaccine. Shingrix is given as two doses, 2 to 6 months apart. In clinical trials, Shingrix prevented shingles in about 90% of vaccinated people age 50 and older. It also prevented post-herpetic neuralgia (the severe nerve pain that can follow shingles) in about 91% of people. These protection rates remained high even in people age 70 and older.

Zostavax is an older vaccine approved in 2006. It uses a weakened form of the live virus. Zostavax is given as a single dose. However, it is less effective than Shingrix, preventing shingles in only about 50% of people age 60 and older. Its protection against post-herpetic neuralgia was even lower. Protection from Zostavax also decreases over time, which means some people vaccinated with it years ago may no longer have adequate protection.

Medicare Part B covers both vaccines, so both are available to you at no cost under Original Medicare. However, the CDC and healthcare organizations now recommend Shingrix over Zostavax for most adults. The higher effectiveness makes Shingrix the better choice for preventing this painful disease. If you previously received Zostavax, the CDC recommends receiving Shingrix as well, since Shingrix provides better protection even in previously vaccinated people. There should be at least 12 months between Zostavax and the first Shingrix dose.

Some people cannot receive Shingrix due to allergies to its components or other medical reasons. In these rare cases, Zostavax may be an option. Your healthcare provider can discuss which vaccine is most appropriate for your health situation.

Practical Takeaway: Shingrix is the newer, more effective vaccine and is the CDC's preferred choice. Ask your healthcare provider about receiving Shingrix rather than Zostavax, as it provides significantly better protection against shingles.

Where to Get Your Shingles Vaccine Under Medicare

You have several options for where to receive your shingles vaccine, and Medicare covers it in most settings. The key is choosing a Medicare-approved provider to ensure your vaccine is properly billed to Medicare with no cost to you.

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Your primary care doctor's office is one common location. Many family medicine doctors, internists, and geriatricians offer shingles vaccines to their Medicare patients. When you call to schedule an appointment for the vaccine, tell the office staff that you want the shingles vaccine and that you have Medicare. The office can confirm they accept Medicare and can administer the vaccine. This option is convenient if you already have an established relationship with your doctor.

Pharmacies are another widely available option. Large pharmacy chains like CVS, Walgreens, and Rite Aid have pharmacists trained to administer vaccines. Many people find this convenient because pharmacies often have extended hours and don't require an appointment. When you visit the pharmacy, bring your Medicare card. The pharmacist will verify your coverage and administer the vaccine. Pharmacies typically bill Medicare directly.

Some Medicare beneficiaries receive care through federally qualified health centers (FQHCs) or community health centers. These centers often offer vaccinations as part of their preventive care services. If you use one of these centers, ask whether they offer the shingles vaccine.

Hospital outpatient departments and urgent care centers may also offer shingles vaccines. These settings typically cost more because they bill facility fees in addition to the vaccine cost, but Medicare covers both. However, it's usually more economical to get the vaccine at your doctor's office or pharmacy.

When choosing where to get vaccinated, verify three things: the provider accepts Medicare, they have the vaccine in stock (or can tell you when it will be available), and they can schedule your second dose appointment if using Shingrix