Confusion on How Medicare Covers the Shingles vaccine?
If you have a Medicare Part D plan, it must cover your shingles vaccine. In fact, all Medicare Part D plans must include all commercially available vaccines on their formularies (list of covered drugs), including the shingles vaccine.
Your Part D plan will pay for the vaccination itself and for your doctor or other health care provider to give you the shot. Before you get a vaccination, you should first check coverage rules with your Part D plan to see where you can get your shot covered at the lowest cost.
You typically pay the least for your shingles shot if you are vaccinated at:
* a pharmacy that is in your drug plan’s network (an “in-network” pharmacy); or
* a doctor’s office that:
* can work with a network pharmacy that will bill your Part D plan for the entire cost of the vaccination; or
* can bill your Part D plan for the vaccine, directly.
If you receive the shot from an in-network pharmacy or from a doctor’s office that can bill your Part D plan, you should only need to pay the plan’s approved copay at the time you get vaccinated.
If you get the shingles vaccine from a doctor’s office that cannot bill your Part D plan, you may need to pay more for it. In this case, you will have to pay the entire cost of the vaccination up front and then follow your Part D plan's rules to get a refund. When you are refunded by the plan, you will only be refunded your Part D plan’s approved amount for the vaccination. Keep in mind that you will be responsible for the difference between the doctor’s charge and the plan’s approved amount.
If you have Extra Help, the federal program that helps pay for your prescription drugs, you can go to any doctor or in-network pharmacy. Your vaccination will be covered and you will only be responsible for the Extra Help copay. However, you may need to pay the entire bill up front and then be reimbursed by your Part D plan, if you get vaccinated by a doctor or health care provider who doesn’t directly bill your Part D plan.
Remember, the only vaccines that Part D doesn’t cover are vaccines that prevent the flu, pneumonia, and hepatitis B. These vaccines are covered under Medicare Part B.