Does Medicare Cover the RSV Vaccine?

Respiratory Syncytial Virus (RSV) is a common respiratory virus that typically causes mild, cold-like symptoms. While many recover quickly, RSV can lead to severe illnesses like pneumonia or bronchiolitis, especially in older adults and those with certain underlying health conditions. A vaccine is now available to protect vulnerable populations from these complications. This article explains how Medicare covers the RSV vaccine, helping beneficiaries understand their options.

General Medicare Coverage for the RSV Vaccine

Medicare generally provides coverage for the Respiratory Syncytial Virus (RSV) vaccine. This immunization is primarily covered under Medicare Part D, which encompasses prescription drug plans. Since 2023, the Centers for Medicare & Medicaid Services (CMS) expanded vaccine coverage, ensuring that all vaccines recommended by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) are included under Part D.

The Inflation Reduction Act of 2022 eliminated out-of-pocket costs for ACIP-recommended vaccines. This means individuals with Medicare Part D typically pay nothing for the RSV vaccine, including deductibles or copayments. While Original Medicare Parts A (Hospital Insurance) and B (Medical Insurance) do not cover the RSV vaccine, Medicare Part B covers other specific vaccines like the seasonal flu shot, pneumonia shots, and certain Hepatitis B and COVID-19 vaccines.

Many Medicare Advantage (Part C) plans also include prescription drug coverage, meaning they will similarly cover the RSV vaccine. If a Medicare Advantage plan does not include drug coverage, a separate Part D plan would be necessary. Without insurance, the RSV vaccine can cost approximately $180 to $550. With Medicare Part D coverage, eligible beneficiaries typically face no direct out-of-pocket costs at the time of vaccination.

Eligibility and Obtaining the Vaccine

Eligibility for the RSV vaccine under Medicare is primarily based on age and health status, aligning with CDC recommendations. The CDC advises all adults aged 75 and older to receive the RSV vaccine. Adults aged 50 to 74 with an increased risk of severe RSV disease are also recommended for vaccination. Risk factors for severe RSV include chronic heart or lung disease, a weakened immune system, other specific medical conditions, or living in a nursing home.

The RSV vaccine is a single dose and is not currently recommended annually. Eligible individuals can receive the vaccine at local pharmacies, primary care physician offices, or community health clinics.

When getting the RSV vaccine, bring your Medicare card and a photo identification. While the vaccine is covered without a copayment or deductible under Part D, beneficiaries should remember their Part D plan may still have a monthly premium. This premium must be paid to maintain coverage and is separate from the vaccine cost.

Confirming Your Specific Medicare Plan Details

While Medicare generally covers the RSV vaccine, understanding your individual plan’s specifics is important. Exact out-of-pocket costs, such as any remaining deductibles or copayments for other medications, can vary significantly between different Medicare Advantage and stand-alone Part D plans. Verifying your plan’s details helps clarify overall coverage.

To confirm your specific coverage, contact your Medicare Advantage or Part D plan directly. The member services phone number is typically on your plan ID card or other documents. Many plans also offer online portals or websites where you can access information about your formulary, vaccine coverage, and other benefits.

Reviewing documents like your Annual Notice of Change (ANOC) or Evidence of Coverage (EOC) can also provide detailed information about your plan’s benefits for the upcoming year. Contacting your plan beforehand ensures you have the most accurate and personalized information, helping you avoid any unexpected administrative issues at the time of vaccination.