Medicare Part C and Shingles Shots: What You Pay

Medicare Part C (Medicare Advantage) covers the shingles vaccine, but your out-of-pocket cost depends on which plan you have and which vaccine your doctor gives you. Most Part C plans cover both Shingrix (the newer, two-dose vaccine) and Zostavax (the older, one-dose vaccine) at no cost or a small copay, but you need to check your specific plan's formulary to know what you will actually pay.

The key difference from Original Medicare is that Part C plans set their own coverage rules within federal guidelines. One plan might cover Shingrix with no copay at a pharmacy, while another might charge $25 per dose or require you to get it at a specific network pharmacy. Your plan documents spell out these details — usually in a section called "Preventive Care" or "Vaccines."

If you are turning 50 or older and have not had shingles, the Centers for Disease Control and Prevention recommends Shingrix, given as two shots two to six months apart. Part C plans are required to cover CDC-recommended vaccines for adults at no cost if you use an in-network provider, but the rules around where you get the shot and which vaccine can vary.

Key Takeaways

  • Most Medicare Part C plans cover shingles vaccines at no cost or a small copay, but your plan's specific coverage depends on which vaccine and which pharmacy you use.
  • Call your plan's customer service number (on your insurance card) and ask whether Shingrix is covered with no copay at in-network pharmacies before you schedule your shot.
  • If your plan covers the vaccine but charges a copay, you may be able to get it at a pharmacy that participates in a vaccine program that waives the copay.
  • Shingrix is the vaccine the CDC recommends for adults 50 and older; if your plan only covers the older Zostavax, ask your doctor whether they can request a coverage exception.

How to Find Out What Your Plan Covers

The fastest way is to call the customer service number on the back of your Medicare Advantage card and ask: "Does my plan cover Shingrix with no copay at in-network pharmacies?" Write down the answer and the name of the person who told you, in case you need to refer back to it.

You can also log into your plan's website and search the formulary or vaccine coverage section. Look for "Shingrix" or "shingles vaccine" — the page should tell you whether it is covered, what you pay, and where you can get it. If the website is unclear, the phone call is faster than trying to decode the document.

Some Part C plans use pharmacy benefit managers (PBMs) that negotiate vaccine pricing separately from the main plan. If your plan says the vaccine is covered but does not say where, ask whether it is covered at CVS, Walgreens, Rite Aid, or your local pharmacy — coverage can differ by pharmacy chain.

In-Network Versus Out-of-Network Pharmacies

Part C plans have networks of pharmacies, just as they have networks of doctors. If you get your shingles shot at an in-network pharmacy, your plan's copay (if any) applies. If you go to an out-of-network pharmacy, you may pay the full price and then have to file a claim to get reimbursed — and reimbursement is not may provide.

Before you schedule your shot, ask your plan which pharmacies are in-network for vaccines. Major chains like CVS, Walgreens, and Rite Aid are in-network for most Part C plans, but independent pharmacies and some regional chains may not be. Your plan's website usually has a pharmacy locator tool, or you can call customer service and ask them to tell you the nearest in-network pharmacy that stocks Shingrix.

What Happens If Your Plan Does Not Cover Shingrix

A small number of Part C plans still cover only Zostavax, the older one-dose shingles vaccine. If your plan is one of them, you have a few options. You can ask your doctor to request a coverage exception — some plans will approve Shingrix if your doctor documents that you cannot take Zostavax for medical reasons. This usually takes a week or two.

You can also pay out of pocket for Shingrix. The cost is typically $150 to $200 per dose (two doses total), so around $300 to $400 for the full series. Some pharmacies offer discounts if you pay cash, so it is worth asking. If you do pay out of pocket, keep your receipts — you may be able to count the cost toward your plan's deductible or out-of-pocket maximum, depending on your plan's rules.

Another option is to switch to a different Part C plan during the annual open enrollment period (October 15 to December 7 each year). If vaccine coverage matters to you, you can compare plans before you enroll and choose one that covers Shingrix with no copay.

Original Medicare Versus Part C Coverage

If you have Original Medicare (Parts A and B) instead of Part C, the coverage rules are different. Original Medicare covers Shingrix at no cost if you get it at an in-network provider, and most pharmacies are in-network for vaccines. You pay nothing out of pocket.

Part C plans must meet or exceed Original Medicare's coverage for preventive care, which means they cannot charge you more than Original Medicare would. In practice, most Part C plans cover shingles vaccines at no cost, just like Original Medicare does. The difference is that Part C plans can set their own rules about where you get the vaccine and which vaccine they cover.

When to Get Your Shingles Shot

The CDC recommends that all adults 50 and older get Shingrix, whether or not they remember having chickenpox. You do not need to wait for a specific time of year — you can get it any time your doctor recommends it and your plan covers it. If you have already had shingles, you should still get Shingrix at least 12 months after the shingles rash healed.

Shingrix is given as two shots, two to six months apart. You can get both shots at the same visit if you want, or space them out. Some people have mild side effects like arm soreness or low-grade fever after the shot, but these go away within a day or two. Serious side effects are rare.

If you are planning other vaccines (like the flu shot or pneumonia vaccine), you can get them at the same visit as Shingrix. There is no waiting period between them.

What to Ask Your Doctor

Before you schedule your shingles shot, ask your doctor: "Is Shingrix recommended for me, and does my Medicare plan cover it?" If your doctor says yes to both, ask them to help you find an in-network pharmacy or to request a coverage exception if your plan does not cover Shingrix.

If you have had shingles before, ask your doctor when you should get Shingrix — the timing depends on how long ago you had shingles and what other health conditions you have. If you take medications that weaken your immune system, ask whether the timing of your vaccine matters.

Frequently Asked Questions

Do I have to pay a copay for the shingles shot with Medicare Part C?

Most Part C plans cover shingles vaccines with no copay at in-network pharmacies, but some charge $10 to $25 per dose. Call your plan's customer service number to find out what you will pay. If your plan charges a copay, ask whether any pharmacies in your area waive it through a vaccine program.

Can I get the shingles shot at my doctor's office instead of a pharmacy?

Yes, many doctors' offices stock Shingrix and can give it to you there. Call your doctor's office and ask whether they have the vaccine in stock and whether your Part C plan covers it when given at the office. Some plans cover it at the doctor's office with no copay but charge a copay at a pharmacy, or vice versa.

What if I had Zostavax years ago — do I still need Shingrix?

Yes. The CDC recommends that anyone who had Zostavax in the past should get Shingrix, even if they had it recently. There is no minimum waiting period, though some doctors recommend waiting at least 12 months. Ask your doctor when you should get Shingrix.

Will my Part C plan cover the shingles shot if I get it while traveling out of state?

Part C plans usually cover preventive vaccines out of network, but you may have to pay upfront and file a claim for reimbursement. Before you travel, call your plan and ask whether out-of-network vaccine coverage is automatic or whether you need to get pre-approval. Bring your insurance card with you.

What if my Part C plan says it does not cover Shingrix?

Ask your doctor to request a coverage exception, which some plans will grant if there is a medical reason you need Shingrix instead of Zostavax. If the exception is denied, you can pay out of pocket (usually $300 to $400 for two doses) or switch to a different Part C plan during open enrollment.