Does Medicare Part B Pay for the RSV Vaccine?
Navigate your Medicare benefits to understand how the RSV vaccine fits into your preventive health plan and what to expect.
Respiratory Syncytial Virus (RSV) is a common respiratory virus, causing mild, cold-like symptoms. For older adults, however, RSV can lead to severe illness, including pneumonia, and may require hospitalization. Each year, RSV contributes to many hospitalizations and deaths among adults aged 60 and older. Effective RSV vaccines are an important advancement in preventive healthcare, prompting questions about Medicare coverage.
Medicare Coverage for RSV Vaccine
Original Medicare, which includes Part A (Hospital Insurance) and Part B (Medical Insurance), does not cover the RSV vaccine directly. While Medicare Part B covers certain preventive services like flu shots, pneumonia shots, and COVID-19 vaccines, it specifically excludes the RSV vaccine. This distinction means that beneficiaries relying solely on Original Medicare would typically face the full cost of the vaccine out-of-pocket.
The RSV vaccine is primarily covered under Medicare Part D, which provides prescription drug coverage. All Medicare Part D plans must cover vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), including the RSV vaccine. Medicare Advantage Plans (Part C) that include prescription drug coverage also cover the RSV vaccine. Recent legislation, such as the Inflation Reduction Act of 2022, has led to $0 out-of-pocket costs for ACIP-recommended adult vaccines under Part D.
How to Get the RSV Vaccine
Medicare beneficiaries seeking the RSV vaccine have several convenient options for receiving their immunization. Many doctor’s offices and local pharmacies, including major retail chains, offer the RSV vaccine. Community health centers and other medical facilities may also provide this preventive service. When planning to get vaccinated, it is advisable to contact the chosen provider beforehand to confirm vaccine availability and scheduling.
Upon arrival, individuals should present their Medicare card and information regarding their Medicare Part D prescription drug plan or Medicare Advantage plan. This allows the provider to accurately bill the correct Medicare coverage for the vaccine. It is important to confirm with the administering staff, whether at a pharmacy or doctor’s office, that they will directly bill your Medicare Part D or Medicare Advantage plan for the vaccine.
While doctor’s offices typically do not require a separate prescription for the RSV vaccine, some states may require a prescription if you choose to receive the vaccine at a pharmacy. Therefore, it is prudent to check with your specific pharmacy in advance regarding any such requirements. The RSV vaccine can safely be administered alongside other routine immunizations, such as the flu shot or COVID-19 vaccine, offering a streamlined approach to preventive care.
Understanding Your Out-of-Pocket Costs
For most Medicare beneficiaries with Part D prescription drug coverage or a Medicare Advantage plan that includes drug benefits, the RSV vaccine typically comes with no out-of-pocket costs. This means individuals should not incur deductibles, copayments, or coinsurance for the vaccine. This $0 cost-sharing is a direct result of recent legislation that eliminated cost barriers for ACIP-recommended vaccines under Medicare Part D.
While the goal is $0 out-of-pocket expenses, verify coverage details with your specific plan. Some variations could occur, particularly if the service is sought from an out-of-network provider or if unique plan nuances apply. The value of Medicare coverage is significant, as the vaccine can cost hundreds of dollars without insurance.
Review your Explanation of Benefits (EOB) after receiving the vaccine, or contact your Part D or Medicare Advantage plan directly. This provides precise information about any charges or coverage specifics, ensuring you understand how the vaccine is covered and can address billing discrepancies promptly.