Shingles, Flu and Pneumonia Shots: Who Should Get Them? Are They Covered?

Shingles vaccine

Did you think that getting older would exempt you from getting vaccinations? No such luck. Certain shots are of great importance for mature adults, and may keep you from contracting a painful or life-threatening illness. Fortunately, it’s easier than ever to take advantage of this health benefit.

Just about every chain pharmacy these days has a sign out front advising that vaccinations are available within. It’s likely that your physician is bringing up the topic at regular appointments, too. So don’t just breeze past those signs and doctor recommendations. Learn what you need to know about shingles, flu, and pneumonia vaccines, and make sure you are protected.

Should I Get a Shingles Vaccine?

Shingles (also known as herpes zoster) is a very painful skin rash that can occur when the chickenpox virus, which can lie dormant in your body, suddenly reactivates. Most shingles cases occur in older people, so the CDC recommends a single dose of the shingles vaccine (also known as Zostavax) for people aged 60 and older, even if they’ve already had a bout of shingles. In clinical trials, the vaccine reduced the risk of shingles by 50 percent.

The nerve pain associated with shingles can be so severe in some people that it disrupts their lives. It starts as a tingling sensation or pain on one side of your body or face. Next, painful skin blisters erupt, typically on the chest, abdomen, back, or face, although it can also affect the limbs and neck. After one to two weeks, the blisters heal and form scabs, but the pain can continue for months.

The shingles vaccine is not recommended if you are allergic to any component of the vaccine or have a weakened immune system. Women who are pregnant should also avoid the vaccine.

Someone with a minor acute illness, such as a cold, may be vaccinated. But anyone with a temperature of 101.3°F or higher should wait until they recover before getting the vaccine.

Is the Shingles Vaccine Covered?

CDPHP and most other insurers require you to be 60 years old before the shingles vaccine (Zostavax) can be covered.

Medicare Advantage plan members: Zostavax is a Part D (drug plan) benefit, not covered by Part B (your medical plan). Knowing your options and asking a few questions can help you lower your out-of-pocket expense and stretch your Part D prescription drug coverage further.

Getting the Zostavax vaccine at a pharmacy that participates with your health plan is a great idea and can help you reduce your out-of-pocket cost. First, ask your primary care provider for a prescription to take with you to the pharmacy. At the pharmacy they can check your Part D benefit status (e.g., donut hole or catastrophic coverage) and let you know exactly what your cost-share will be prior to administering the vaccine.

If you choose to get the vaccine in a doctor’s office or other outpatient site, it is possible that you will be asked to pay the full cost up front and file a claim form with your pharmacy benefits provider (which is CVS Caremark if you have a Part D benefit through CDPHP).

Unlike Zostavax, both the flu shot and pneumonia vaccinations are considered Part B (medical) benefits.

Get a Flu Shot Every Year

The best way to avoid getting the flu is to get an annual flu shot. The vaccine is reformulated each year to be effective against that season’s virus. It is appropriate for just about anyone aged six months and older, so check with your doctor and arrange to get one if you have not already. As they are fully covered by CDPHP and most other insurances, cost should never be an excuse to skip your yearly flu vaccine.

Many participating provider offices offer flu clinics to make it easy to get one after hours. Adult members also have the option of getting the shot at a participating pharmacy, such as CVS or Price Chopper. If for some reason you are asked to pay upfront for this covered benefit, simply submit a claim for reimbursement.

Get a Pneumonia Vaccine and Boosters as Recommended

Following your doctor’s advice regarding pneumonia vaccination may save your life. According to the CDC, about a million people are hospitalized with pneumonia each year in the United States, and about 50,000 people die from the disease. Most of these hospitalizations and deaths involve adults.

Avoid unnecessary illness: Ask your doctor whether you are due for any preventive immunizations. The pneumonia vaccine, when recommended by your physician, is fully covered by all CDPHP plan types, including CDPHP Medicare Choices.


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