Does Medicare Cover the RSV Vaccine?

Respiratory Syncytial Virus (RSV) is a common respiratory virus. While often causing mild, cold-like symptoms, it can lead to severe illnesses in some individuals. Vaccines are now available to help protect against RSV.

Current Medicare Coverage for RSV Vaccine

Medicare beneficiaries generally find coverage for the RSV vaccine through their Medicare Part D prescription drug plans. This coverage means that for most individuals, there are no out-of-pocket costs associated with receiving the vaccine. This beneficial provision, which eliminates deductibles, copayments, and coinsurance, was established as of January 1, 2023, through the Inflation Reduction Act.

The Inflation Reduction Act significantly changed vaccine coverage under Medicare Part D, ensuring that all vaccines recommended by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) are covered without cost-sharing. This legislative change made it more accessible for older adults to receive important preventive immunizations like the RSV vaccine.

While Medicare Part D is the primary avenue for RSV vaccine coverage, Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) typically do not cover this specific vaccine. Medicare Part B does cover other preventive vaccines, such as those for influenza, pneumococcal disease, and COVID-19. However, the RSV vaccine, being a newer development, falls under the Part D benefit.

It is important to note that this no-cost coverage applies to FDA-approved RSV vaccines. If a vaccine is administered in a doctor’s office rather than a pharmacy, beneficiaries might be asked to pay the cost upfront. In such cases, they can then submit a reimbursement request to their Medicare Part D plan for the full amount.

Eligibility and How to Get Your Vaccine

Eligibility for the RSV vaccine under Medicare coverage aligns with the recommendations set forth by the CDC’s Advisory Committee on Immunization Practices (ACIP). The ACIP recommends a single dose of the RSV vaccine for all adults aged 75 years and older. For adults aged 60 to 74 years, the vaccine is recommended based on shared clinical decision-making with a healthcare provider, particularly if they are at increased risk for severe RSV disease.

Individuals considered to be at increased risk include those with chronic medical conditions such as:
Cardiovascular diseases
Chronic lung or respiratory disease
End-stage renal disease
Diabetes with chronic kidney disease
Neurological or neuromuscular conditions
Chronic liver disease
Chronic hematologic conditions
Severe obesity
Moderate to severe immune compromise

Individuals residing in nursing homes or other long-term care facilities are also typically considered at increased risk. Unlike some other vaccines, the RSV vaccine is not currently an annual immunization; a single dose is expected to provide protection for at least two RSV seasons.

Medicare beneficiaries have several convenient options for obtaining their RSV vaccine. The vaccine is widely available at retail pharmacies, many doctor’s offices, and various clinics. Before visiting, it is advisable to contact your specific Medicare Part D plan or healthcare provider to confirm preferred vaccination locations and to inquire about appointment scheduling.

Understanding Costs and What to Expect

While rare, a cost might arise if a beneficiary’s specific plan or provider does not adhere to standard billing practices for Part D covered vaccines, or if the vaccine was received prior to the full implementation of the no-cost provision. In such scenarios, if an upfront payment is made, beneficiaries can typically seek full reimbursement from their Part D plan by submitting the necessary documentation.

When you go to receive your RSV vaccine, you can expect a straightforward process. A healthcare professional will typically conduct a brief screening to ensure you meet the eligibility criteria and have no contraindications. The vaccine is administered as a single injection, usually into the upper arm. Following the injection, you may be asked to remain for a short observation period, a common practice after vaccinations. Common side effects, which are generally mild and temporary, can include pain, redness, or swelling at the injection site, along with fatigue, headache, or muscle aches.