Paul Sanchez
Shingles is a viral infection caused by the same virus as chickenpox, and it affects about 1 million people in the US each year. The SHINGRIX vaccine is the only one approved in the US to prevent shingles. It is recommended for people aged 50 and older, and those 19 and older with weakened immune systems. The cost of the vaccine varies depending on insurance coverage and other factors. So, does medical insurance cover the cost of the shingles vaccine?
| Characteristics | Values |
|---|---|
| Does medical insurance cover the shingles vaccine? | Yes, most insurance plans cover the shingles vaccine. |
| Which insurance plans cover the shingles vaccine? | ACA, private health insurance, Medicare Part D, and Medicaid. |
| How much do insured individuals pay for the shingles vaccine? | Most people with insurance pay nothing for the shingles vaccine. However, some may pay less than $5 per dose. |
| How much does the shingles vaccine cost without insurance? | A full course of the shingles vaccine costs $366.82 or $183.41 per dose. |
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What You'll Learn
Shingles vaccine cost
The cost of the shingles vaccine depends on several factors, including insurance coverage, the patient's age, and the state of residence.
Shingrix is the only FDA-approved vaccine for the prevention of shingles (herpes zoster) in adults 18 years and older who are at an increased risk of shingles due to a compromised immune system. It is not used to prevent chickenpox.
Insurance Coverage
The Affordable Care Act (ACA) and the Inflation Reduction Act of 2022 have made it so that certain vaccines, including the shingles vaccine, incur no out-of-pocket costs for people with ACA plans, private health insurance, or Medicare Part D. This means that most people with insurance will pay nothing for the shingles vaccine.
Out-of-Pocket Costs
For those without insurance, the shingles vaccine can cost about $366.82 for the complete 2-dose regimen, or about $183.41 per dose. The lowest price for the Shingrix vaccine is about $151, but this does not include administration fees. The average retail price per dose can be about $213, and some pharmacies offer it for $170.99.
Medicaid
Medicaid enrollees will likely pay less than $5 per dose for Shingrix in most parts of the US. More than two-thirds of states and the District of Columbia have expanded their Medicaid programs to cover Shingrix, while the remaining states are less likely to do so.
Medicare
Medicare Part D covers the shingles vaccine, and all Medicare Part D patients pay $0 per dose. However, most doctors' offices cannot bill for vaccinations for Part D enrollees, so patients may need to receive the vaccine at a pharmacy or ensure their doctor's office can bill under Medicare Part D.
State Variations
Coverage and cost may vary from state to state and are subject to change without notice. Reimbursement decisions are made by individual insurance plans.
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SHINGRIX coverage
SHINGRIX is an FDA-approved vaccine for the prevention of shingles (herpes zoster) in adults 18 years and older who are or will be at increased risk of shingles due to being immunocompromised by known disease or therapy. It is not used to prevent chickenpox.
Insurance plans covering 96% of commercially insured members cover SHINGRIX. 96% of privately insured individuals pay $0 for the vaccine. The Affordable Care Act (ACA) requires all Health Insurance Marketplace plans and most other private health insurance plans to cover all ACIP-recommended vaccines, including SHINGRIX, with no cost-sharing if administered in-network.
Medicare Part D patients pay an out-of-pocket cost of $0 per dose. The Inflation Reduction Act removes cost-sharing for ACIP-recommended adult vaccines covered under Medicare Part D, meaning people with Part D will pay $0 for SHINGRIX.
The cost of SHINGRIX for those paying out of pocket varies individually. GSK offers programs to help patients without insurance cover the cost of their medications, including SHINGRIX.
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Medicare Part D coverage
Medicare Part D covers the shingles vaccine, Shingrix, recommended by the Centers for Disease Control and Prevention (CDC) for healthy adults 50 years and older. The vaccine is also suggested for people 19 and older with weakened immune systems.
Medicare Part D is a prescription drug coverage plan, and as of 2023, all Medicare-covered vaccines should be free. This means that there should be no copayment, coinsurance, or deductible for the covered vaccines. The Affordable Care Act (ACA) and the Inflation Reduction Act of 2022 also ensure that people with ACA plans, private health insurance, or Medicare Part D cannot be charged out-of-pocket costs for certain vaccines, including the shingles vaccine.
Medicare Part D covers most commercially available vaccines, with the exception of the flu, pneumonia, hepatitis B, and COVID-19 vaccinations, which are covered by Part B.
Medicare Advantage Plan (Part C) also covers the shingles vaccine if it includes Medicare Part D drug coverage.
Medicaid expansion has also increased the likelihood of Shingrix coverage, with most states and the District of Columbia expanding their programs. However, the remaining states that have not expanded their Medicaid programs are less likely to cover Shingrix.
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Private insurance coverage
Private health insurance coverage for the shingles vaccine varies depending on the insurance provider and the specific plan. However, in general, most private insurance plans cover the shingles vaccine with no out-of-pocket costs for the insured.
The Affordable Care Act (ACA) requires all Health Insurance Marketplace plans and most other private health insurance plans to cover all ACIP-recommended vaccines, including the shingles vaccine, with no cost-sharing if administered in-network. This means that 96% of privately insured people pay nothing for the shingles vaccine.
It is important to note that the shingles vaccine is recommended for people 50 and older, as well as for individuals with weakened immune systems, who are at a higher risk of developing shingles. The vaccine is effective in preventing shingles and its potential long-term complications, such as postherpetic neuralgia (PHN), which can cause severe pain that lasts for months or even years.
While most private insurance plans cover the shingles vaccine, it is always a good idea to check with your specific insurance provider to confirm coverage details and understand any potential out-of-pocket costs. Additionally, it is worth noting that some states have expanded their Medicaid programs to cover the shingles vaccine, so this may be another option for individuals seeking coverage.
For those without insurance, there are options available to help with the cost of the shingles vaccine. GSK, for example, offers programs to assist patients without insurance in accessing the vaccine. Additionally, individuals can visit websites like HealthCare.gov to explore affordable health coverage options and learn more about state health department immunization programs that may offer the shingles vaccine.
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Medicaid coverage
Medicaid covers all necessary vaccines for children and may cover certain adult vaccines, including the shingles vaccine. However, vaccine coverage for adults varies by state, and some states choose not to cover adult vaccines at all.
Shingrix is the only vaccine approved in the US to prevent shingles. The vaccine is recommended for healthy people over 50 and individuals over 19 with weakened immune systems. The CDC recommends that individuals in these categories receive two shots of the vaccine.
Medicaid likely covers Shingrix in the 38 states with expanded Medicaid coverage and the District of Columbia. In these states, the average copayment for covered beneficiaries is less than $5 per shot. If you live in a state without expanded Medicaid coverage, it is less likely that Shingrix will be covered.
To find out whether the shingles vaccine is included in your state's Medicaid coverage, you can contact your state's Medicaid office.
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Frequently asked questions
The shingles vaccine is covered by most insurance plans. According to the Affordable Care Act, insurance plans that cover children allow parents to add or keep adult children on their health insurance policy until they turn 26 years old.
A full course of the shingles vaccine costs $366.82 or $183.41 per dose. However, most people with insurance will pay nothing for the vaccine.
The shingles vaccine (Shingrix) is an FDA-approved vaccine for the prevention of shingles (herpes zoster) in adults 18 years and older who are or will be at an increased risk of shingles due to a weakened immune system.
