Does Medicaid Cover Shingrix?
- Does Medicaid cover Shingrix? Find out if Shingrix is free for Medicaid beneficiaries and whether it's covered by Medicare and private health care insurance.
Shingrix is one of the two commercially available shingles vaccines. It helps prevent shingles, a painful rash caused by the chickenpox virus. Shingles can cause serious complications, and older adults are at a greater risk of complications than the rest of the population. Shingrix is an effective way to protect yourself from shingles, but it's relatively expensive out of pocket. So, does Medicaid cover Shingrix? Below, you can find out whether Medicaid covers the shingles vaccine and why it's so pricy.
Does Medicaid Cover Shingrix?
Medicaid may cover Shingrix, but coverage for vaccines varies widely across states. Although all states are required to cover necessary childhood vaccines through Medicaid, they can choose whether to cover adult vaccines like Shingrix.
Medicaid beneficiaries are more likely to be covered for Shingrix vaccines if their state is one of the 38 with expanded coverage. States without expanded Medicaid may still cover Shingrix, but it's less likely. You can find out if your state has expanded Medicaid coverage through the Medicaid site.
Eligible enrollees usually won't need to pay for a shingles vaccine through Medicaid at an in-network clinic. However, you may be charged a small copayment, which is less than $5 on average.
Does Medicare Cover Shingrix?
Medicare Part A and B (Original Medicare) doesn't cover shingles vaccines, including Shingrix. However, Part D Medicare plans purchased through a third-party insurer often cover Shingrix. You may also be covered for the Shingrix vaccine if you have a Medicare Advantage Plan that includes Part D coverage.
However, the cost of your annual Part D deductible may exceed the cost of your Shingrix vaccine if you haven't already paid it, so it may be more cost-effective to pay for your vaccine out of pocket.
Is Shingrix Free for Seniors?
The Shingrix vaccine isn't automatically free for seniors. However, many seniors will have private health care insurance that covers Shingrix. According to the Shingrix website, the vaccine is included in 90% of private health care plans, with average costs of less than $5 per shot. You may also be eligible for a free Shingrix vaccine if you have Medicare Part D insurance.
The Affordable Care Act (ACA) requires that most private health care insurance plans must cover preventative health care, including vaccines, without cost-sharing. This means that many insurers aren't allowed to charge beneficiaries for vaccines like Shingrix. However, most providers require you to have your vaccine at an in-network facility to get your vaccine free.
Why Is Shingrix so Expensive?
The Shingrix vaccine is relatively expensive, and you should expect to pay around $200 per shot out of pocket. There are several reasons why the Shingrix vaccine is so costly, including local shortages and the fact that the vaccine is a brand-name product.
Unlike the influenza, COVID-19 and pneumococcal vaccines, which Original Medicare may cover, Medicare classes Shingrix as a prescription drug even though the CDC recommends it for adults over 50. Furthermore, there isn't an unbranded version of the shingles vaccine, which means that the commercially available vaccines are often part of the more expensive Tier 3 and 4 formularies in Part D plans.
You'll generally get your Shingrix vaccine for free if your state covers it and you're a Medicaid beneficiary or you have a private plan covered by the ACA. However, many people end up paying for their Shingrix vaccine out-of-pocket because they haven't paid their deductible if they have Medicare Part D or can't find a suitable facility in their insurer's network.