Does Medicare Cover the RSV Vaccine?
Medicare Part D and some Medicare Advantage plans will pay for your RSV vaccine.
Original Medicare (Parts A and B) won't pay for the new Respiratory Syncytial Virus (RSV) vaccine. To get RSV vaccine coverage you need a Medicare Advantage plan with prescription drug coverage or a separate prescription drug plan, called Medicare Part D.
Does Medicare cover the RSV vaccine?
Medicare Part D and Medicare Advantage plans with prescription drug coverage will cover the RSV vaccine. You're not responsible for paying any costs when you get the RSV vaccine.
Original Medicare (Parts A and B) won't pay for an RSV vaccine.
About 15.5 million Medicare enrollees don't have coverage for the RSV vaccine. Roughly 50.5 million of the 66 million Medicare enrollees in the U.S. have prescription drug coverage through Part D or a Medicare Advantage plan.
Some Medicare Part D and Medicare Advantage plans with prescription coverage haven't added the RSV vaccine to their list of covered drugs yet. You still have RSV vaccine coverage even if it hasn't been added to your plan.
You can ask the company that runs your Medicare Advantage or Part D plan to pay for the RSV vaccine by requesting what's called a coverage exception. Otherwise, you can pay for the vaccine out of pocket and get reimbursed afterward.
Medicare Part B will not pay for the RSV vaccine. However, Medicare Part B has coverage for the flu, pneumonia and COVID-19 vaccines. It will also pay for some vaccines your doctor asks for, such as the tuberculosis vaccine if you have a bad cut or burn.
Does Medicare Advantage (Part C) cover the RSV vaccine?
Only Medicare Advantage plans that include prescription drug coverage will pay for your RSV vaccine.
You will have to pay out of pocket for the RSV vaccine if you have a Medicare Advantage plan that doesn't have prescription drug coverage.
Medicare Advantage is bundled coverage that you get through a private company. All Medicare Advantage plans are required by law to offer the same coverage you'd get through Original Medicare. Many plans include extra coverage, such as prescription drugs, vision and dental.
How much does the RSV vaccine cost?
The RSV vaccine typically costs between $180 and $295 if you don't have insurance. How much you pay depends on where you live, and the vaccine can cost over $300 in some areas.
Is the RSV vaccine covered by insurance?
Private health insurance plans have to cover the RSV vaccine for those age 60 and older.
However, that coverage won't continue once you turn 65 and get on Medicare unless you buy a Medicare Part D or Medicare Advantage plan with prescription drug coverage.
Doctors recommend that people between 60 and 74 get an RSV vaccine if they meet or have one of the following conditions.
Everyone age 75 and older should get an RSV vaccine according to the Centers for Disease Control and Prevention (CDC).
Where can you get an RSV vaccine?
You can get an RSV vaccine at many pharmacies. That includes major retailers such as Walgreens, Walmart and Safeway. Call your local pharmacy to set an appointment after you speak with your doctor. You may need a prescription if you're between 60 and 64.
What is the RSV vaccine?
The vaccine protects against the respiratory syncytial virus (RSV), which has symptoms similar to the common cold. In serious cases, it may cause lung infections.
The RSV vaccine is typically given in a single dose and lasts for two winter seasons.
The Food and Drug Administration (FDA) has approved three RSV vaccines.
- GSK's AREXVY
- Moderna's mRESVIA
- Pfizer's ABRYSVO
You can see which vaccine your plan will pay for by checking its list of covered drugs, called a formulary. Call your Medicare company if your plan doesn't list one or more of these drugs. You may have to request what's called a coverage exception.
RSV generally isn't harmful to healthy adults and children. However, it can prove deadly for infants and the elderly. Every year roughly 60,000 to 160,000 older adults are hospitalized and about 6,000 to 10,000 die from RSV.
Frequently asked questions
Does Medicare cover the RSV vaccine?
Medicare Part D and some Medicare Advantage plans will pay for the RSV vaccine. However, Original Medicare (Parts A and B) doesn't offer RSV vaccine coverage.
Is the RSV vaccine covered by insurance?
Yes, most private insurance plans are required to cover RSV vaccines. However, short-term health insurance and plans bought on or before March 23, 2010, called grandfathered plans, don't have to pay for RSV vaccines.
Should seniors get the RSV vaccine now?
You should get the RSV vaccine if you're 75 or older. If you're between 60 and 74, talk to your doctor. You may need an RSV vaccine if you have a qualifying medical condition, such as an ongoing heart or lung disease.
Is the RSV vaccine covered by Medicare Part B?
No, the RSV vaccine isn't covered by Medicare Part B. Medicare Part B covers regular medical (outpatient) care and vaccines for the flu, pneumonia and COVID-19, as well as some vaccines requested by your doctor, such as the hepatitis B vaccine.
Sources
Medicare drug coverage rules were taken from the Centers for Medicare & Medicaid Services (CMS). Information related to the RSV virus and approved vaccines came from the Centers for Disease Control and Prevention (CDC).
Medicare Part D coverage statistics and vaccine cost estimates were taken from KFF.
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