Why Does My Shingles Vaccine Cost So Much?
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If you're covered by Medicare, you may feel the pain of a shingles shot more in your wallet than in your arm.
That's because the federal program that insures most seniors in the U.S. provides poor coverage for some recommended vaccines, including shingles, and could leave some people paying $200 or more for protection.
Shingles is a viral infection that often causes a painful, blistering rash and, in some cases, leads to lingering nerve pain and, in rare cases, even blindness.
The vaccine isn't foolproof, but for people aged 60 and older it reduces the risk of getting shingles by about 51 percent and, if you do get shingles, reduces the nerve pain it causes by close to 70 percent, according to the Centers for Disease Control and Prevention.
Some Vaccines Covered Better Than Others
Unlike the flu and pneumonia vaccines, which are fully covered as preventive services under Medicare Part B, the shingles shot and other recommended vaccinations are covered as prescription drugs under Medicare Part D and Medicare Advantage plans.
Some of those plans provide better coverage than others, but nearly all of them divide their formularies, or list of covered drugs, into tiers according to cost. Drugs in Tier 1 and 2, mainly lower-priced generics and “preferred brand-name” drugs, have lower co-pays than more expensive “nonpreferred brands” in Tier 3 or 4.
Consumer Reports found that many Part D plans categorize the shingles vaccine, Zostavax, as an expensive Tier 3 or 4 drug. Only one pharmaceutical company—Merck—makes the shingles shot, and there’s currently no generic version.
That means if you haven’t met your annual deductible, you’ll likely wind up paying full price for the shot, which is about $217. But depending on your plan, even after the deductible is met, consumers may have to pay a significant part of the shingles vaccine cost—up to $100.
Many healthcare providers haven’t set up billing systems to file claims through prescription drug plans. So if you're vaccinated at your doctor’s office, you might be required to pay the full shingles vaccine cost up front and then file to be reimbursed by your insurance.
Other Types of Plans Do Better
Other forms of insurance do a far better job covering immunizations.
Under provisions of the Affordable Care Act, private plans—such as insurance through your employer or purchased on a state marketplace—are still required to cover recommended vaccinations as preventive medical care, not drugs.
That means that as long as you go to a provider in your plan’s network, your insurance will pay for preventive care without a co-pay, even if you haven’t met your deductible.
“It’s really a shame that older Americans, who are most at risk of contracting shingles and most vulnerable to the potentially serious effects of the disease, often have to pay more than others for the vaccine,” says Consumer Reports’ medical director, Orly Avitzur, M.D.
If you’re currently covered by a private health plan but anticipate going on Medicare in the next five years or so, one cost-saving strategy is to talk to your doctor about updating all your vaccinations now while your insurance provides good coverage, Avitzur says. The shingles shot is recommended for nearly all adults aged 60 and older.
Don't Overpay: Advice for Medicare Patients
Three out of four Americans eligible for the shingles vaccination still haven’t gotten it, according to the CDC. Not surprisingly, a 2015 report from the National Vaccine Program found that one of the main reasons adults skip recommended vaccines is the cost.
If you’ve been putting off getting your shingles shot because you were quoted a high price, check your Part D plan. You may be able to get it for less.
“Confusion about insurance coverage for the vaccine can sometimes result in patients paying more than they should,” Avitzur says.
“Don’t delay, as the consequences of shingles can be devastating,” advises Avitzur, a neurologist who has seen firsthand the painful effects of lingering nerve damage.
Your best bet may be to get the shot at a pharmacy in your drug plan’s network. You’ll still need to get a prescription from your doctor, but the pharmacy will bill your insurance company and you’ll pay the lowest out-of-pocket costs available under your plan.
If you would like to get vaccinated at your doctor’s office, ask up front about the cost. Does your doctor charge more to administer the shot than your plan allows? If so, you’ll be on the hook for the difference. Also see whether the office will bill your Part D or Medicare Advantage plan directly or work with a pharmacy in your network to handle the billing.
And last, if you don’t have health insurance or you're experiencing medical or financial hardship, you might qualify for Merck’s Vaccine Patient Assistance Program, which provides free vaccinations to those who are eligible. For details, go to merckhelps.com.
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