Toni,
I was told to receive a shingles vaccination. I need to be enrolled in a Part D prescription drug plan for the vaccination to have a $0 copay or pay $200. I thought all vaccinations and immunizations are covered at no cost under Medicare Part B.
Can you explain this Medicare rule? Thank you.
— Carl from Lubbock, Texas
Carl,
On Jan. 1, 2023, the Inflation Reduction Act eliminated all out-of-pocket costs for vaccines recommended for adults by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. This important Medicare change went into effect whether you have drug coverage from a stand-alone Medicare Part D prescription drug plan or from a Medicare Advantage plan with Part D coverage. The shingles vaccine, also known as Shingrix, is included at no cost.
Carl, I hope you are enrolled in a Medicare Part D plan, or you will have to pay more than $200 per dose for Shingrix, which the Food and Drug Administration approved in 2017. Not being enrolled in a Part D or Advantage plan with Part D coverage is why you were told you might have to pay over $200 per dose for the vaccine.
It is very important for those leaving employer group health insurance after 65 or enrolling in Medicare for the first time (when turning 65 or before 65, if eligible) to be sure to enroll in a Medicare Part D stand-alone prescription drug plan, with or without a Medicare supplement, or a Medicare Advantage plan with Part D. Having the shingles shot covered with a $0 copay is an important reason Americans should enroll in a Medicare Part D plan when eligible.
Those with a Medicare Part D plan can receive their shingles vaccine at the pharmacy or doctor’s office. If you have trouble affording the Medicare Part D prescription drug premium, you may qualify for Medicare’s Extra Help program that assists people with limited income and assets to pay premiums and out-of-pocket costs for Part D drug coverage.
Page 50 of the 2024 “Medicare and You” handbook explains how flu, hepatitis, pneumonia and COVID-19 vaccines are covered under Medicare Part B. Shots are covered under Medicare and you won’t pay anything for the shot as long as your doctor or other health care provider accepts Medicare assignment. Always verify your doctor is accepting Medicare assignment.
The “Medicare and You” handbook states that Medicare Part B will cover vaccines to prevent:
— Influenza, currently the seasonal flu shot (page 42).
— Hepatitis B if you are at medium or high risk (page 42).
— Pneumococcal shots for pneumonia (page 48).
— COVID-19 vaccines and testing (page 37).
On page 50, the handbook also says that, for shots not covered under Medicare Part B, Part D generally covers all other recommended adult immunizations to prevent illness (like shingles, tetanus, diphtheria, pertussis and respiratory syncytial virus, aka RSV) at no cost to you. The handbook advises you to, if your shot is not on the Medicare list, ask for a coverage exception and to talk with your doctor about which immunizations are right for you.
Part B will cover other immunizations, but only if you are exposed to a disease or condition, such as a tetanus shot if injured by a rusty nail or rabies if bitten by a dog or strange animal.
It amazes me how Medicare can make a simple medical issue such as getting a vaccine so complicated. Remember, with Medicare, it’s what you don’t know that will hurt you.
Toni King is an author and columnist on Medicare and health insurance issues. She has spent nearly 30 years as a top sales leader in the field. If you have a Medicare question, email info@tonisays.com or call 832-519-8664. Toni’s books and her newsletter are available at tonisays.com. Toni’s new “Confused about Medicare” video series is now available for purchase at tonisays.com, as are Toni’s “Medicare Survival Guide” and discounted bundle package.