Does Medicare Cover the RSV Vaccine Shots?

Respiratory Syncytial Virus (RSV) is a common respiratory virus that causes mild, cold-like symptoms. While many people recover within a week or two, RSV can lead to severe illness, particularly for older adults and individuals with certain underlying health conditions. This can include serious conditions such as pneumonia or bronchiolitis, potentially requiring hospitalization. Effective RSV vaccines protect vulnerable populations from severe outcomes.

Medicare Coverage for RSV Shots

Medicare covers the RSV shot through its prescription drug benefit. The RSV vaccine is covered under Medicare Part D. This coverage extends to all adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC).

Original Medicare, Part A and Part B, does not cover the RSV vaccine. While Part B covers certain preventive vaccines like flu, pneumonia, and Hepatitis B, the RSV vaccine falls under Part D. Beneficiaries with Original Medicare need a Part D plan for RSV shot coverage.

Individuals enrolled in Medicare Advantage (Part C) plans also cover the RSV shot. Medicare Advantage plans are offered by private companies and must provide at least the same coverage as Original Medicare. Many Medicare Advantage plans include prescription drug coverage, so the RSV vaccine is covered under these plans.

Eligibility and Costs

Medicare beneficiaries aged 60 and older are eligible to receive the RSV shot. A discussion with a healthcare provider can assess individual health factors and risk levels. Adults between 60 and 74 years with specific health conditions that increase their risk for severe RSV may also be recommended for the vaccine.

Beneficiaries with Medicare Part D pay nothing out-of-pocket for the RSV vaccine. This zero cost-sharing is a result of the Inflation Reduction Act of 2022, which eliminated deductibles and copayments for ACIP-recommended adult vaccines covered under Medicare Part D.

For those with Medicare Advantage plans that include prescription drug coverage, the RSV shot is also covered with no cost-sharing. While Part D plans have monthly premiums, the vaccine itself will not incur additional charges.

Getting Your RSV Shot

Consult with your healthcare provider to determine if the vaccine is appropriate for your health situation. They can provide a recommendation based on your individual needs.

The RSV shot can be administered in various healthcare settings. Common locations include your doctor’s office, local pharmacies, or other clinical settings. Bring your Medicare card and any identification for your specific Medicare Advantage or Part D plan to your appointment.

To locate a provider or pharmacy that offers the RSV shot and accepts your Medicare coverage, utilize official Medicare resources. The Medicare.gov website provides online tools to find healthcare providers and compare services. You can also contact your specific Medicare Part D or Medicare Advantage plan directly for assistance in finding covered providers.