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Shingles Shots and Treatment under Medicare Part D

October 6, 2016

Shingles is a viral condition that results in a painful rash forming on the sides of the face or torso, according to the Centers for Disease Control and Prevention. The condition isn’t generally life-threatening, but the symptoms can be excruciatingly painful. Fortunately, getting the shingles vaccine can reduce your risk of contracting this condition. Here is an overview of the condition and Medicare coverage for the shingles vaccine and treatment.

What is shingles?

According to the Centers for Disease Control and Prevention (CDC), shingles is caused by the varicella zoster virus, the same virus that causes chickenpox. People who get shingles as adults typically had chickenpox as children. After you get chickenpox, the varicella virus stays dormant in your body and may be reactivated years later as shingles. It’s unclear what causes the virus to reactivate, though people who have weakened immune systems may have a higher risk of developing shingles.

Anyone who has had chickenpox can get shingles, and your risk increases with age. According to the CDC, shingles can’t be transmitted from person to person. However, it’s possible for someone with shingles to infect another person with chickenpox if the person exposed to the virus has never had chickenpox. The same virus causes both conditions.

People with shingles often get a single swath of blisters on one side of the body or face. A few days before the rash appears, infected patients usually have pain or itching in the same area. Other symptoms of shingles can include chills, fever, headaches, or indigestion. The rash and other symptoms typically go away within two to four weeks.

Shingles and older adults

This condition primarily affects older adults, and the symptoms tend to be more severe for seniors. Over half of all shingles infections are among individuals 60 and older, according to the (CDC). Not only are older adults at higher risk for getting shingles, they’re also more likely to develop complications like post-herpetic neuralgia. As the CDC explains, patients with post-herpetic neuralgia have severe pain that can remain long after the rash has healed. In the worst cases (which are rare), complications from shingles can cause hearing and vision problems, blindness, or death.

Treatment and prevention of shingles

To treat shingles, your doctor may prescribe antiviral drugs. Antiviral medications can help reduce the duration and severity of the infection if the drugs are taken immediately after the rash appears. Because immediacy is key to the effectiveness of antiviral treatment, it’s important to see a doctor as soon as symptoms develop. Pain medications like analgesics can also help relieve symptoms.

One of the most important things you can do to protect yourself from the virus is to get the shingles vaccination. The Food and Drug Administration has approved the shingles vaccine Zostavax for adults age 60 and older. The CDC recommends that adults age 60 and older get the shingles vaccine, regardless of whether they’ve had chickenpox.

If you’ve had chickenpox, the shingles shot reduces the risk of the varicella zoster virus reactivating to form shingles. The vaccine is recommended even if you’ve had shingles previously since it can prevent future occurrences.

Zostavax isn’t recommended for adults with compromised immune systems, however. Talk to your doctor about whether you should get the shingles vaccine.

Medicare coverage of shingles

Most stand-alone Medicare Part D Prescription Drug Plans and Medicare Advantage Prescription Drug plans provide coverage for the shingles vaccine; however, coverage can vary depending on your chosen plan and the pharmacy or physician that administers the vaccine. Stand-alone Medicare Part D Prescription Drug Plans and Medicare Advantage Prescription Drug plans are offered by private insurance companies contracted with Medicare to provide Medicare Part D prescription drug coverage. A stand-alone Medicare Part D Prescription Drug Plan works in conjunction with your Original Medicare Part A (hospital insurance) and/or Part B (medical insurance) coverage. Medicare Advantage Prescription Drug plans, on the other hand, combine health and prescription drug coverage, providing at least the same level of health coverage as available in Part A and Part B (except hospice care, which continues to be covered by Part A). If you are not currently enrolled in a Medicare plan offering prescription drug coverage you may do so at various times, including the Initial Enrollment Period, when you first become eligible for Medicare, the Annual Election Period, occurring October 15 – December 7 each year when you may sign up for a Medicare Advantage plan or a Medicare Part D Prescription Drug Plan, change plans, or return to Original Medicare, the General Enrollment Period, which occurs between January 1 and March 31, if you did not enroll in Medicare during the Initial Enrollment Period, and in some cases during a Special Enrollment Period.

If you are enrolled in a Medicare plan with prescription drug coverage, review your benefits to determine that the shingles vaccine is covered by the plan and what your copayment or coinsurance (out-of-pocket cost) is.  Cost and coverage can vary by plan. Plans may have different procedures that need to be followed in order for you to receive the value of this benefit. For example, some Medicare Part D Prescription Drug Plans and Medicare Advantage Prescription Drug plans may require prior authorization for the shingles vaccine. Some plans may have benefit provisions that reduce your out-of-pocket expense for the shingles vaccine if you receive the vaccine from a network participating pharmacy; others may have benefit provisions that encourage you to receive the shingles vaccine from your doctor. Therefore, you may wish to contact your plan and inquire about any upfront costs you may have to pay and how to be reimbursed for those costs or a portion of the expense of the shingles vaccine. Ask about where you should receive the shingles vaccine—from your doctor or from a network-participating pharmacy— to maximize your benefit coverage.

Original Medicare Part A and Part B do not cover the shingles vaccine. In fact, Original Medicare has very limited prescription drug coverage. If you have shingles, Medicare Part B generally covers outpatient care, including but not limited to, physician services and laboratory tests. Copayments, coinsurance, and deductibles may apply. And as is the case anytime you receive covered services under Original Medicare Part A and Part B, your out-of-pocket medical expense is generally lower if you receive care from health-care providers who accept Medicare assignment.

This information is provided for educational purposes only. It is not to be used for medical advice, diagnosis or treatment. Consult your doctor if you have questions or concerns.