Shingles, pneumococcal, RSV and Tdap are the four adult vaccines most often missed. A Prescott internist explains who needs each one, how long protection lasts, and why nearly all of them cost $0 on Medicare.
Most of my Prescott patients over 60 can tell me the exact month they got their flu shot. Ask about shingles, pneumonia, RSV or tetanus, and I usually get a pause. The national data backs up that pause: only 35.0% of adults 65 and older have completed the two-dose shingles series, according to CDC AdultVaxView surveillance.
So this article is about the four adult vaccines that are not the flu shot. I have covered influenza separately in my fall flu season update for Prescott, and I will leave that topic there. What follows is shingles, pneumococcal, RSV and Tdap: who needs each one, how long protection actually lasts, what they cost on Medicare, and the specific things patients get wrong.
One caveat first, and I would rather you hear it from your physician than stumble across it. The federal adult immunization schedule is operating under a court order right now. It does not change any of the four vaccines below. But you deserve to know the ground you are standing on.
Key Takeaways
- Pneumococcal vaccination starts at 50, not 65. ACIP lowered the age in October 2024, and one dose of PCV20 or PCV21 now completes the series for most adults.
- Shingrix is two doses at age 50 and older, even if you have already had shingles or the older Zostavax. It was still 73.2% effective at year 10 in long-term follow-up.
- The RSV vaccine is not annual. If you got it in a previous season, you should not get another one.
- The 10-year tetanus rule only covers clean, minor wounds. For a dirty or major wound, the threshold drops to 5 years.
- All four cost $0 for most Medicare beneficiaries: pneumococcal under Part B, and shingles, RSV and Tdap under Part D.
Why is the adult vaccine schedule under a court order right now?
On March 16, 2026, in American Academy of Pediatrics v. Kennedy, the U.S. District Court for the District of Massachusetts stayed the HHS Secretary’s ACIP appointments and stayed every vote taken at ACIP’s June, September and December 2025 meetings. CDC’s schedule page now states it plainly: “The July 2, 2025 schedule is currently in effect.”
Here is the reassuring part, and it is the reason I am comfortable writing this article at all. All four vaccines discussed below were recommended by ACIP votes taken before June 2025. None of these four recommendations are affected by the stay. The contested items were COVID-19 vaccination, the hepatitis B birth dose, and MMRV.
What that means practically: shingles, pneumococcal, RSV and Tdap guidance is stable. It is the same guidance your pharmacist and your insurer have been working from. Because federal recommendations are actively in litigation, though, confirm anything you read anywhere, including here, with your own physician before you act on it.
Who needs the shingles vaccine, and how long does it protect you?
About 1 in 3 people in the United States will develop herpes zoster during their lifetime, roughly 1 million U.S. cases a year, with risk climbing sharply after age 50. The recommendation is two doses of the recombinant zoster vaccine at age 50 and older, given 2 to 6 months apart.
CDC’s adult schedule notes are unusually direct about this: the two doses are indicated “regardless of prior herpes zoster or previous zoster vaccine history.” For immunocompromised adults, vaccination starts at 19 and the interval may be shortened to 1 to 2 months.
Why I push on this one: shingles is not just a rash. Between 10% and 18% of people who get shingles also develop postherpetic neuralgia, the nerve pain that can outlast the rash by months or years. I have watched it end a patient’s gardening season, and occasionally her independence.
How well does Shingrix work, and does it wear off?
Efficacy in the pivotal trials was 97% at ages 50 to 69, 91% at 70 and older, and 91% against postherpetic neuralgia. The more useful question for a 68-year-old is what happens a decade later. The ZOSTER-049 long-term follow-up study answered it:
- Year 1: 97.7% efficacy
- Year 4: 89.8%
- Year 7: 83.3%
- Year 10: 73.2%
Pooled efficacy across years 5 through 10 was 81.6%. That is the single most reassuring data point in this article. Protection declines, but slowly, and it is still substantial at ten years. There is currently no recommended booster after the two-dose series.
What if I already had shingles, or got the old Zostavax?
Get Shingrix anyway. Having had shingles does not protect you from a second episode, and the older live vaccine was considerably weaker: Zostavax efficacy was 41% at ages 70 to 79 and 18% at 80 and older. It has not been available in the United States since November 18, 2020. If you received it, wait at least 8 weeks and then start the Shingrix series.
Three practical points I repeat weekly in the exam room. If your second dose is overdue, CDC is explicit: do not restart the vaccine series, just get the second dose. Second, the series only works if you finish it. Published U.S. claims analysis of adults newly eligible at 50 found that fewer than three in four finish the series within a year of starting it. Third, sore arm and a day of feeling lousy after dose two is common and expected. It is not a reason to skip the dose that does most of the work.
The pneumonia vaccine now starts at 50, not 65
This is the biggest correction in this article. ACIP voted on October 23, 2024 to lower the pneumococcal vaccination age from 65 to 50, published in MMWR in January 2025. A single dose of PCV15, PCV20 or PCV21 is now recommended for all pneumococcal-vaccine-naive adults aged 50 and older.
The second change matters just as much and almost nobody has heard it. If PCV20 or PCV21 is used, one dose completes the series. No PPSV23 follow-up is needed. Only if PCV15 is used do you still need PPSV23 at least a year later. The old ritual of two pneumonia shots a year apart is retired for most people.
What if you have already had a pneumococcal shot?
CDC’s catch-up guidance depends on what you got:
- PCV13 only: one dose of PCV20 or PCV21, at least one year later.
- PPSV23 only: one dose of PCV21, PCV20 or PCV15, at least one year later.
- Both, with PPSV23 given at 65 or older: shared decision-making with your physician about one dose of PCV20 or PCV21, at least 5 years after your last dose.
If you cannot remember which one you got, you are in good company. This is exactly the kind of thing a primary care office should have on file, and it is why I keep a running immunization list for every patient rather than reconstructing it during an acute visit.
How much disease does this actually prevent?
Invasive pneumococcal disease incidence is 13.2 per 100,000 at ages 50 to 64 and 17.2 per 100,000 at 65 and older, which is what drove the age change. Serotype coverage improved too: the serotypes in PCV20 accounted for 56% of adult cases, while PCV21 covers 83%.
On efficacy, I want to be precise, because a lot of marketing is not. The CAPiTA trial of 84,496 adults aged 65 and older found 45.6% efficacy against vaccine-type pneumonia and 75.0% against vaccine-type invasive disease. Those numbers belong to PCV13. PCV20 and PCV21 were licensed on immunogenicity bridging, not on repeat efficacy trials, so it is not accurate to attach CAPiTA’s figures to them.
Is the RSV vaccine an annual shot like the flu vaccine?
No, and this is the most common misconception I hear. CDC states it directly: “The RSV vaccine is not currently an annual vaccine.” Among adults 65 and older, RSV causes roughly 60,000 to 160,000 hospitalizations and 6,000 to 10,000 deaths each year, so one well-timed dose carries real weight.
The recommendation is a single dose for all adults 75 and older, and a single dose for adults aged 50 to 74 who are at increased risk and have not been vaccinated. If you received an RSV vaccine in a previous season, you should not get another one. And it is no longer a shared-decision-making vaccine. ACIP replaced that vaguer framing with explicit age and risk criteria in June 2024.
What counts as increased risk between ages 50 and 74?
CDC’s risk conditions include chronic cardiovascular disease, chronic lung disease, end-stage renal disease, diabetes with end-organ damage or requiring insulin, neurologic conditions that impair airway clearance, cirrhosis, sickle cell disease or thalassemia, severe obesity with a BMI of 40 or above, moderate or severe immune compromise, and residence in a nursing home.
Two more belong on that list and they are the ones that matter locally: frailty, and residence in a remote or rural community. If you live out past Williamson Valley or in Paulden and your nearest emergency department is a long drive, that distance is itself part of the risk calculation. I have had that conversation with patients who were surprised to learn geography counts.
How well does it work, and did I miss the window?
First-season efficacy against RSV lower respiratory tract disease was 82.6% for Arexvy, 88.9% for Abrysvo and 80.9% for mResvia, per Immunize.org’s clinical summary. Second-season figures were 56.1%, 78.6% and 48.4%. Real-world data from 2023-24 in adults 60 and older showed roughly 83% protection against hospitalization for Arexvy and about 73% for Abrysvo.
The ideal window is late summer to early fall, before RSV circulation picks up. If you are reading this in November, that window has passed. Get it anyway. RSV season runs for months, and a dose given during the season still protects you for the remainder of it, plus the seasons after.
Does a tetanus shot every 10 years actually cover you?
Not for every injury, and this is the point I most want Prescott readers to take away. The familiar 10-year rule applies only to clean, minor wounds. For a dirty or major wound, CDC’s wound management guidance sets the threshold at 5 years. Most patients believe 10 years covers everything.
Think about how people here actually get hurt. A puncture from a rake in soil. A deep scrape on granite off a Thumb Butte trail. Barbed wire on a ranch fence line. A chainsaw slip clearing fuel load before fire season. Those are contaminated wounds, and the clock on them is half as long as you think.
| Your tetanus vaccination history | Clean, minor wound | Dirty or major wound |
|---|---|---|
| Complete series, last dose under 5 years ago | No vaccination needed | No vaccination needed |
| Complete series, last dose 5 to 9 years ago | No vaccination needed | Vaccinate |
| Complete series, last dose 10 or more years ago | Vaccinate | Vaccinate |
| Unknown or incomplete history | Vaccinate | Vaccinate |
Td or Tdap? The difference is pertussis.
Every adult who has never received Tdap should get one dose, regardless of the interval since the last tetanus-containing shot. After that, Td or Tdap every 10 years. Pregnant patients need one dose during every pregnancy, preferably in weeks 27 through 36.
Here is the wrinkle. That routine 10-year booster is often given as plain Td, which contains no pertussis component. So a patient can be perfectly up to date on tetanus and carry zero recent whooping cough protection. If you are going to be around a new baby and you have never had Tdap, get it, ideally at least two weeks beforehand so your immune response has time to develop.
One technical note for readers 65 and older: Either Tdap product is immunogenic in adults 65 and older, and CDC advises that providers “should not miss an opportunity to vaccinate.” If the office has the other brand in the refrigerator, take it.
What do these four vaccines cost on Medicare?
For most beneficiaries, nothing. Pneumococcal vaccination is covered under Part B, and you pay nothing if your provider accepts assignment. Shingles, RSV and Tdap fall under Part D, where you also pay nothing. Since January 1, 2023, the Inflation Reduction Act eliminated all cost sharing for ACIP-recommended Part D vaccines.
| Vaccine | Medicare coverage | What you pay |
|---|---|---|
| Pneumococcal (PCV15, PCV20, PCV21, PPSV23) | Part B | $0 if your provider accepts assignment |
| Shingles (Shingrix), both doses | Part D | $0, no deductible or copay |
| RSV (Arexvy, Abrysvo, mResvia) | Part D | $0, no deductible or copay |
| Tdap or Td | Part D | $0, no deductible or copay |
No deductible, no copay, no coinsurance, regardless of which benefit phase you are in. That is a genuine change from the recent past, and plenty of patients are still operating on old information.
What it used to cost, and what changed
In 2021, the average out-of-pocket cost was $77 for shingles, $51 for hepatitis B and $28 for Tdap. That year, 3.4 million Part D enrollees paid $234 million out of pocket for vaccines. Price was a real barrier, not an imagined one.
After the policy changed, 10.3 million Part D enrollees received a $0 vaccine in 2023, avoiding roughly $400 million in costs. Shingles vaccine recipients rose 42% compared with 2021, and Tdap recipients rose 114%. A corroborating natural experiment points the same direction: among Medicare beneficiaries 65 and older, shingles vaccination was 45.2% among those with prescription drug coverage versus 25.3% among those without.
So why did the pharmacy quote me a price?
Because of billing plumbing, not coverage. A pneumococcal shot given in a doctor’s office bills to Part B and comes out free. A shingles shot bills to Part D, and many physician offices are simply not set up to bill Part D. So patients get sent to a pharmacy, or occasionally get quoted a cash price at the desk.
That is a mechanics problem, not a benefits problem. If someone quotes you $200 for Shingrix and you have Part D, that is your signal to ask where the claim is being submitted, not to walk away from the vaccine.
Why are so many adults still unvaccinated?
The coverage numbers are sobering. Among adults 65 and older, CDC AdultVaxView reports 64.7% have had at least one pneumococcal dose, 59.2% have had tetanus vaccination within 10 years, and only 35.0% have completed the two-dose shingles series. Among adults 50 and older, shingles series completion is just 28.7%.
Read that one more time. Roughly 1 in 3 adults 65 and older have completed the two-dose shingles series, even though 1 in 3 people will get shingles in their lifetime and the vaccine is free. RSV coverage among adults 75 and older was 41.5% at the end of the 2024-25 season.
Arizona is not uniformly behind. State-level BRFSS data from 2024 puts pneumococcal coverage among Arizona adults 65 and older at 72.0%, These come from a different survey than the national estimates above, so read them as separate measurements rather than a head-to-head comparison.
In my experience the barrier is almost never refusal. It is that nobody has a complete list. Vaccines get scattered across a pharmacy, an urgent care, a hospital stay and two former primary care offices, and the record fragments. That is the same reason I built a decade-by-decade screening schedule for my patients: preventive care fails at the tracking step far more often than at the decision step.
Where can you get these vaccines in Prescott?
You have more options than you might think. Under A.R.S. section 32-1974, an Arizona pharmacist may order and administer CDC-recommended immunizations to anyone aged 6 and older without a prescription. Pharmacists must report administrations to the Arizona State Immunization Information System and must notify your primary care provider within 48 hours.
Pharmacies do this work well, and I send patients to them regularly. But I want to be honest about the limits of that 48-hour notification. It only works if the pharmacy has your correct primary care provider on file, which frequently is not the case after a move or a practice change.
More importantly, a notification says a vaccine was given. It does not reconcile which pneumococcal product you received, whether that product completes your series, or whether you are due for a second Shingrix dose in April. Somebody has to keep the master list and act on it. In a direct primary care practice that is straightforward, because I have the time and the panel size to actually look. Wherever you get your care, ask who is doing that job for you.
The four things patients get wrong most often
These four misconceptions account for most of the missed doses I see. The most expensive one is the pneumococcal age threshold, which changed when ACIP voted in October 2024 to lower it from 65 to 50. Fifteen years of eligibility opened up overnight and the message has not fully landed.
- “The pneumonia shot starts at 65.” Wrong since October 2024. It starts at 50. If you are between 50 and 64 and pneumococcal-naive, you are eligible today.
- “I already had the shingles shot,” or “I already had shingles, so I do not need it.” Both wrong. Shingrix is recommended regardless of prior zoster or prior zoster vaccine. If your prior shot was Zostavax, that vaccine was only 18% effective at 80 and older.
- “The shingles shot is expensive.” Not since January 2023. It is $0 under Part D, both doses, in every benefit phase.
- “The RSV shot is annual like the flu shot.” It is not. One dose. If you had it last season, do not get another.
What should you do before your next visit?
Start by writing down what you can actually document: which vaccines, which year, which product if the record shows it. Then bring that list to your physician rather than reconstructing it from memory in the exam room. Four vaccines, one conversation, and for most Medicare beneficiaries, a $0 balance at the end.
If you are 50 or older and have never had a pneumococcal vaccine, that is the highest-yield gap on the list right now. If you started Shingrix and never finished, you do not restart, you just finish. If you are 75 or older and have never had RSV vaccination, November is late but far from useless. And if your last tetanus shot was 8 years ago and you garden, hike or work outdoors, know that a dirty wound puts you past due, not comfortably covered.
These are exactly the decisions that suffer in a seven-minute appointment and improve enormously with an unhurried one. If you would like to review your immunization history in detail, reach out to the office and we will go through it together.
This article is general medical information, not personal medical advice. Federal immunization recommendations are currently subject to ongoing litigation, so confirm current guidance with your own physician before making vaccination decisions.
Frequently Asked Questions
Do I need the shingles vaccine if I already had shingles?
Yes. CDC recommends two doses of Shingrix at age 50 and older regardless of prior herpes zoster or previous zoster vaccine history. Having had shingles does not reliably prevent a second episode, and about 1 in 3 Americans develop shingles during their lifetime. Talk with your physician about timing after an active episode.
Is the pneumonia vaccine really recommended starting at age 50 now?
Yes. ACIP voted on October 23, 2024 to lower the age from 65 to 50, published in MMWR on January 8, 2025. Pneumococcal-naive adults 50 and older need one dose of PCV15, PCV20 or PCV21. If PCV20 or PCV21 is used, that single dose completes the series.
Do I need an RSV vaccine every year like the flu shot?
No. CDC states the RSV vaccine is not currently an annual vaccine. It is a single dose for all adults 75 and older, and for adults 50 to 74 with increased-risk conditions. If you were vaccinated in a previous season, you should not receive another dose.
How much do these vaccines cost with Medicare?
For most beneficiaries, nothing. Pneumococcal vaccination is covered under Part B with no cost if your provider accepts assignment. Shingles, RSV and Tdap fall under Part D, where the Inflation Reduction Act eliminated all cost sharing as of January 1, 2023: no deductible, no copay, any benefit phase.
My last tetanus shot was 8 years ago. Am I covered if I cut myself gardening?
Possibly not. The 10-year rule applies only to clean, minor wounds. For a dirty or major wound, including soil-contaminated punctures and deep scrapes, CDC sets the threshold at 5 years. At 8 years out you would need a tetanus-containing vaccine for a contaminated injury. Seek care promptly.
Does the March 2026 court order change these recommendations?
No. The court stayed ACIP votes from the June, September and December 2025 meetings, and CDC states the July 2, 2025 schedule is currently in effect. All four vaccines here were recommended by earlier votes, so none are affected. The contested items were COVID-19, hepatitis B birth dose and MMRV.
Can an Arizona pharmacist give me these vaccines without a prescription?
Yes. Under A.R.S. section 32-1974, Arizona pharmacists may order and administer CDC-recommended immunizations to anyone aged 6 and older without a prescription. They must report to the Arizona State Immunization Information System and notify your primary care provider within 48 hours, so keep your provider information current.