Free Guide to Medicare Shingles Vaccine Coverage Options

How Medicare Covers the Shingles Vaccine

The shingles vaccine protects against herpes zoster, a painful viral infection that affects about one in three Americans at some point in their lives. Medicare Part B covers two shingles vaccines for people age 50 and older: Shingrix and Zostavax. Understanding how Medicare pays for these vaccines can help you make informed decisions about your health care.

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Shingrix is a two-dose vaccine given as injections two to six months apart. Medicare Part B covers both doses with no out-of-pocket cost to you after you meet your Part B deductible. For 2024, the Part B deductible is $240 per year. Once you meet this deductible, you pay nothing for the shingles vaccine doses themselves. Zostavax is a single-dose vaccine that is also covered by Medicare Part B, though it is less commonly used now because Shingrix is more effective.

The coverage applies whether you receive the vaccine at a doctor's office, hospital outpatient department, pharmacy, or other Medicare-approved provider. The provider bills Medicare directly for the vaccine and administration. You do not need to pay upfront and then wait for reimbursement. Instead, Medicare processes the claim and handles payment to the provider.

One important detail: if you received Zostavax in the past, you can still get Shingrix. There is no waiting period required between the two vaccines. Some people who received Zostavax years ago have since received Shingrix for better protection. Medicare covers this scenario.

Takeaway: Medicare Part B covers shingles vaccines for people 50 and older. After meeting your annual deductible, the vaccine costs you nothing. Both Shingrix and Zostavax are covered options, though Shingrix is preferred due to higher effectiveness rates.

Understanding Medicare Part B Coverage Details

Medicare Part B is the part of Original Medicare that covers doctor visits, outpatient care, and preventive services—including vaccines. To have Part B coverage for the shingles vaccine, you must be enrolled in Part B. Most people become eligible for Medicare at age 65, but some people younger than 65 may also qualify due to disability or end-stage renal disease.

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Part B requires a monthly premium that most people pay through Social Security deductions. In 2024, the standard Part B premium is $164.90 per month, though some people pay more based on their income. Even if you have Part B, you still have an annual deductible. After you pay this deductible in a calendar year, Medicare covers 80 percent of most services, and you are responsible for the remaining 20 percent as coinsurance.

Here is how this works with the shingles vaccine: Let's say you have not yet met your Part B deductible for the year. You go to your doctor's office to get your first Shingrix dose. The vaccine and administration cost about $150 to $200 total. This amount counts toward your deductible. If your deductible is $240, you might pay the full amount out of pocket until you reach $240 in services for the year. Once you meet the deductible, Medicare covers the vaccine at no additional cost to you.

The rules are different if you receive the vaccine at a hospital outpatient department. In that setting, you typically pay 20 percent coinsurance after meeting your deductible. However, when vaccines are given in a doctor's office or pharmacy, the coinsurance rules are often more favorable. Many doctor's offices and pharmacies cover the full cost after your deductible is met.

Takeaway: Part B covers the shingles vaccine only after you meet your annual deductible. Understanding where you get the vaccine matters—doctor's offices and pharmacies may have different cost structures than hospital outpatient departments.

Medicare Advantage Plans and Shingles Vaccine Coverage

Medicare Advantage plans, also called Part C, are an alternative to Original Medicare. These plans are offered by private insurance companies and must cover all services that Original Medicare covers, including the shingles vaccine. However, the way Medicare Advantage plans handle vaccine coverage can differ from Original Medicare.

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Most Medicare Advantage plans cover the shingles vaccine with no out-of-pocket cost after you meet your plan's deductible—similar to Original Medicare. Many plans have no deductible for preventive vaccines, which means you may pay nothing at all. Some plans cover vaccines at preferred pharmacies or providers with lower costs. Plans might also waive the deductible for preventive services like vaccines.

The specifics depend on your individual plan. Your plan's summary of benefits, sometimes called the "Evidence of Coverage" document, lists what vaccines are covered and what you pay. You can find this document on your plan's website or by calling the plan's member services phone number, which appears on your insurance card.

Here is a practical example: Sarah has a Medicare Advantage plan with a $250 deductible and a $25 copay for specialist visits. She calls her plan to ask about the shingles vaccine cost. The plan representative tells her that preventive vaccines, including Shingrix, have no copay and do not count toward her deductible. Sarah can get both doses at no cost. This situation is common, though not universal.

If you are thinking about switching to a different Medicare Advantage plan, vaccine coverage is one factor to consider. Plans change their coverage and costs each year during the annual enrollment period in October and November. Reviewing your plan's vaccine coverage before the new year can help you understand what to expect.

Takeaway: Medicare Advantage plans must cover the shingles vaccine, but the exact cost varies by plan. Review your plan's coverage documents or contact member services to learn your specific out-of-pocket costs.

The Two Doses of Shingrix and Timing

Shingrix requires two doses to provide full protection against shingles. The second dose should be given two to six months after the first dose. Both doses are necessary because studies show that one dose alone does not provide adequate protection. The vaccine's effectiveness is around 90 percent when both doses are completed, compared to about 50 percent for Zostavax, the older single-dose vaccine.

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Medicare covers both doses of Shingrix. Each dose counts as a separate service, and you may have two separate claims submitted to Medicare. If you receive both doses in the same calendar year, each dose will count toward meeting your Part B deductible. If you receive the first dose late in the year and the second dose early in the next year, the second dose will count toward the next year's deductible.

Here is a timeline example: You receive your first Shingrix dose in November. This dose costs $150 and counts toward your $240 deductible. You have met $150 of your deductible. In January of the next year, you receive your second dose. You now have a new $240 deductible for that year. The second dose might count toward this new deductible, or if your plan covers preventive vaccines fully, you might pay nothing.

Some people delay getting the second dose because of cost concerns or scheduling difficulties. However, delaying the second dose beyond six months from the first dose does not reduce the vaccine's effectiveness. If more than six months pass, the second dose will still work. There is no need to restart the series by getting a new first dose. You simply get the second dose when you are ready.

It is important to keep records of when you received each dose. You can ask your provider for documentation, or check your Medicare claims online through your account on Medicare.gov. Having this information helps you and your doctor track your vaccination status and know when you are fully protected.

Takeaway: Both doses of Shingrix are covered by Medicare. Plan to receive the second dose two to six months after the first, and keep records of when each dose is given.

Where You Can Get the Shingles Vaccine

You can receive the shingles vaccine in several settings, and Medicare covers it in all of them. The main options are doctor's offices, pharmacies, community health centers, and hospital outpatient departments. Each location has different advantages.

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Doctor's offices remain a common place to get the shingles vaccine. Your primary care doctor or any licensed physician can administer Shingrix