Understanding Shingles & How Medicare Works
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Shingles is a painful and relatively severe condition caused by a complication of the varicella-zoster virus, otherwise known as the chickenpox virus. A sufferer can pass this virus onto someone else, although they will contract chickenpox rather than shingles.
After you’ve had chickenpox, the virus lies dormant in nerve tissues near your brain and spinal cord. Even years after the initial illness, this virus can reactivate as shingles, especially if your immune system is weak because of stress or certain conditions. Shingles is more likely to occur when a patient is over 50.
The first symptom of shingles is pain, which can be very intense. Shingles also features an itchy rash, but only on a small section of one side of your body. The rash is red and painful to touch and can have the sensation of burning, numbness, or tingling. Fluid-filled blisters will form before breaking open and crusting open.
Some people will also experience fever, headaches, fatigue, and a sensitivity to light. Sometimes, the shingles pain can remain long after the blisters have gone, this is known as postherpetic neuralgia. While shingles isn’t typically life-threatening, it is very disruptive and difficult to live with, and complications can make it even more severe.
One way to prevent shingles is to avoid contracting chickenpox, as only someone who has had chickenpox can develop shingles. However, this isn’t always possible. While chickenpox is less common than it once was, more than 95% of American adults have had chickenpox before and there are still 4 million cases every year.
Another, more viable, way to prevent the shingles is the shingles vaccine. In the US, this would be Shingrix, a non-living vaccine comprised of a virus component. It is given in two doses, with between two and six months between doses.
While this vaccine doesn’t guarantee that you won’t get shingles, it will reduce the likelihood. The shingles vaccine also lessens the severity of the disease and reduces the risk of complications like postherpetic neuralgia. This protection lasts at least five years.
The full cost of Shingrex is $162 for a single dose, so the recommended two doses would amount to $324. This price, as well as the recommendation for those over 50 to get a vaccination, leads many people to ask “does Medicare cover shingles vaccine?”
While the shingles vaccine is recommended by the CDC for those over 50 years of age, it isn’t fully covered by Original Medicare. This is partially because Shingrex is a Tier 3 drug without a generic alternative, which makes it more expensive than other medications. It’s also related to how Shingrex is classified by Medicare.
So, even if you’re eligible for some Medicare plans, you may still have to pay full price for your vaccination. But some other Medicare plans do cover the shingles vaccines.
Original Medicare, now known as Medicare Part A (hospital insurance) or Part B (medical insurance) does not cover the shingles vaccine. While Medicare Part B doesn’t cover the vaccine itself, it may cover a doctor’s visit to get your prescription for the shingles vaccine. Medigap also doesn’t cover the shingles vaccine.
Medicare Part C (Medicare Advantage) is a bundled plan that typically includes Parts A, B, and drug coverage. Most of these bundles will cover the shingles vaccine, although it always pays to check. Finally, Medicare Part D (prescription drug plan) does cover the vaccine, as long as you get a prescription. But before enrolling in Part D, make sure you know how to avoid the Part D penalty, or that paying the penalty is worth it.
So, if you have either Medicare Part D or Medicare Advantage, your shingles vaccine will be covered. However, coverage amounts can vary. For some, the vaccine could be free or under $50 per dose, but if your cost-sharing benefits depend on a deductible, you may have to pay full price.
The deductible on your Medicare plan directly affects how much you need to pay for your medication or care before your insurer contributes to the costs. Many plans don’t have a deductible for Tier 1 and 2 drugs, but as a Tier 3 drug, Shingrex is often affected.
Always check the details of your Medicaid plan to check whether or not it covers the costs of your prescriptions. Everyone’s circumstances are different, meaning that different plans are better for different people. Plans that don’t have deductibles tend to have a higher monthly cost, meaning that you don’t actually save any money on your healthcare.
However, you can save money on a shingles vaccine in some other ways. If you have a lower income, look for pharmaceutical assistance programs that may help you reduce the cost of prescription drugs. Give us a call at (888) 352-6672 if you would like some help weighing your options.
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We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.