UNITED STATES—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, TX.
Carl: On January 1, 2023, the Inflation Reduction Act eliminated all out-of- pocket costs for vaccines which the CDC’s Advisory Committee on Immunization Practices recommended for adults. 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 that you might have to pay over $200 per dose for the vaccine.
It is 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 at your 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 pay premiums and out-of-pocket costs for Part D drug coverage.
Page 50 of the 2024 Medicare & You handbook explains how shots (or vaccines) flu, hepatitis, pneumonia shots and COVID-19 vaccines are covered under Medicare Part B. The handbook states that shots are covered under Medicare and that you may pay nothing for the shot as long as your doctor or other health care providers accepts Medicare assignment. Always verify that your doctor is accepting Medicare assignment.
Below is what page in the Medicare and You handbook that Medicare Part B will cover vaccines to prevent:
- Influenza (the flu) currently the seasonal flu shot, See pg. 42.
- Hepatitis B (if you are at medium or high risk), See pg. 42.
- Pneumococcal Shots (Pneumonia), See pg. 48.
- COVID-19 vaccines and testing, See pg. 37.
Under “Important” on pg. 50, the handbook says that, for shots not covered under Medicare Part B that Part D “generally covers other recommended adult immunizations to prevent illness (like shingles, tetanus, diphtheria, and pertussis and respiratory syncytial virus (RSV) at no cost to you.” The handbook advises you, 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! If you have a Medicare question, email in**@to******.com or call 832-519-8664. Toni’s new Confused about Medicare” video series is available at www.tonisays.com.
Written By Toni King