Medicare and the shingles vaccine
Q: My doctor says he can't bill Original Medicare for my shingles vaccine, but I thought Medicare would cover one. Does Medicare cover the shingles vaccine?
A: Your doctor is right; he should not bill Original Medicare for the shingles vaccine.
Unlike some other vaccines that are covered by Medicare Part B, the shingles vaccine is covered by Part D. This is the same part of Medicare that you use when you buy prescription drugs at your pharmacy or through the mail. People get Part D through either a private, stand-alone prescription drug plan (if they also have Original Medicare) or a Medicare Advantage plan with drugs.
The shingles vaccine is covered by your Medicare prescription drug plan because drug plans are required by law to cover any commercially available vaccine that is not covered by Part B when the vaccine is medically necessary to prevent illness.
Your Part D plan will pay for the vaccination itself and for your doctor or other health care provider to administer the shot. However, you will need to make sure you follow your particular plan's rules and networks for the vaccine to be covered.
You will pay the least for the shingles vaccine if you are vaccinated at:
- a pharmacy that is in your drug plan's network if this is permitted in your state; or
- a doctor's office that can work with a pharmacy that will bill your Part D plan for the entire cost of the vaccination process; or
- a doctor's office that can bill your plan directly, using a special computer billing system.
In these situations, you should need to pay only the plan's approved co-insurance or co-pay. You may need to pay more for your vaccination if:
- your doctor cannot submit the bill to your Part D plan through a partnering pharmacy; or
- your doctor does not directly bill your plan for the drug using the electronic billing system.
In these situations, your doctor can bill you for the entire cost of the vaccination and you will pay the entire bill up front. You will then follow your Part D plan's rules to be reimbursed.
Before you get a shingles vaccine, check with your Part D plan's coverage rules and learn where you can get your vaccine so it will be covered at the lowest cost.
Source: Centers for Medicare and Medicaid Services