Does Medicare Cover the RSV Shot?

Respiratory Syncytial Virus (RSV) is a common respiratory virus that often causes mild, cold-like symptoms. It can, however, lead to more severe respiratory infections, particularly in vulnerable populations. RSV is a leading cause of conditions such as bronchiolitis and pneumonia, especially among infants and older adults. The development of RSV vaccines offers a layer of protection, helping to prevent serious illness and reduce the need for hospitalization.

Medicare Coverage of the RSV Shot

Medicare provides coverage for the Respiratory Syncytial Virus (RSV) vaccine primarily through its Part D prescription drug plans. This coverage extends to both standalone Medicare Part D plans and Medicare Advantage (Part C) plans that incorporate prescription drug benefits. Original Medicare Parts A and B do not cover the RSV vaccine directly. The vaccine is included because it is a routine adult immunization recommended by the Centers for Disease Control and Prevention (CDC)’s Advisory Committee on Immunization Practices (ACIP).

Medicare Part D covers all commercially available vaccines that ACIP recommends, ensuring access to immunizations like the RSV shot. ACIP specifically recommends the RSV vaccine for adults aged 60 and older, with particular emphasis on those 75 and older, and individuals aged 60-74 who have underlying health conditions that increase their risk. This ensures eligible beneficiaries receive coverage.

Understanding Your Costs

Due to the Inflation Reduction Act of 2022, Medicare Part D beneficiaries face no out-of-pocket costs for ACIP-recommended vaccines, including the RSV vaccine. This means that deductibles, copayments, and coinsurance do not apply for this immunization. This change, effective January 1, 2023, aims to make vaccines more accessible.

While the vaccine itself is covered at no cost, beneficiaries still pay their monthly Medicare Part D plan premiums, which can vary. Medicare Advantage plans that include prescription drug coverage also provide the RSV vaccine with no out-of-pocket expenses. For individuals without Medicare Part D coverage, the out-of-pocket cost for the RSV vaccine can range from approximately $180 to $550. Consult your plan documents or contact your plan directly for cost details.

Accessing the RSV Shot

Medicare beneficiaries have several options for receiving the RSV vaccine. Common locations for administration include local pharmacies, doctor’s offices, and community health clinics. When seeking the vaccine, it is recommended to confirm that the chosen provider accepts your specific Medicare Part D or Medicare Advantage plan.

Bring your Medicare card and your prescription drug plan card to your appointment. Some healthcare providers, particularly doctor’s offices, may refer patients to pharmacies for Part D-covered vaccines due to differences in reimbursement structures. For a list of preferred providers or pharmacies within your plan’s network, contacting your Medicare plan directly or visiting their official website can provide guidance.