How coverage of the shingles shot works under TRICARE is a common question among retirees. TRICARE covers the shingles vaccine two different ways – under your medical coverage, or under your pharmacy coverage. Our guidance below can help you understand which one you want to use and take the appropriate action.
[TRICARE.MIL: The Shingles Vaccine]
Age 64 and Under, and Not on TRICARE For Life (TFL)
All TRICARE Prime plans, U.S. Family Health Plans (USFHP), and TRICARE Select plans cover the full cost of the shot, at no cost to you, whether administered by a pharmacy under the pharmacy coverage or at a doctor’s office under the medical coverage.
Beneficiaries using any TRICARE Prime plan can go to any TRICARE network pharmacy, primary care manager, or network provider. USFHP members must use their USFHP pharmacy or primary care manager. Those using a TRICARE Select plan can go to any TRICARE network pharmacy or any TRICARE-authorized provider.
On TRICARE For Life (Normally Age 65 and Over)
Medicare is your primary health coverage under Parts A and B. Medicare covers the shingles shot but does so as a pharmacy issue under the pharmacy Part D insurance, not under Parts A or B (learn more at this link). Most military retirees do not have Part D coverage because we use our TRICARE pharmacy plan. In our cases, Medicare will not cover the shot; the entire cost falls to TRICARE For Life as your Medicare supplement.
For those of you still under the USFHP, stay within your USFHP plan pharmacy or primary care managers for your coverage.
Having another pharmacy program besides our TRICARE pharmacy plan disqualifies us from the TRICARE home delivery program and can cause us to file manual claims to TRICARE pharmacy for reimbursement (learn more at this link). So, we do not want a Part D plan.
Based on the above, TRICARE becomes your shingles shot insurance. You have two TRICARE options to get the shot.
1. The easiest and cheapest option: Use your TRICARE pharmacy benefit coverage by going to a TRICARE network pharmacy for the shot. You can get the shingles vaccine for free at a participating TRICARE network pharmacy. That’s it.
2. Go to your doctor for the shot. This isn’t the best option, because Medicare will not be picking up any of the cost for retirees. Under this option, TFL covers the shingles shot as a medical coverage, not pharmacy coverage. So, the process goes like this:
- You get the shingles shot at the doctor’s office.
- Medicare won’t cover the shot because you do not have Part D Medicare, so the total cost falls to TFL.
- TFL covers the shot as a medical cost not covered by Medicare Parts A nor B.
- When medical costs are not covered by Medicare, TFL deductibles and cost shares apply. The deductible is $150 for individual coverage ($300 for families), and you may face a 20% co-pay after the deductible (learn more about costs at this link). Bottom line: You pay for the shot.
[RELATED: MOAA's TRICARE Guide]
Choose wisely under TFL. Whether pharmacy or medical coverage is used makes a big difference.