Does Medicare Part D Cover the RSV Vaccine?
Navigate Medicare Part D coverage for the RSV vaccine. Discover current policies, out-of-pocket costs, and steps to get vaccinated.
The Respiratory Syncytial Virus (RSV) can cause significant respiratory illness, particularly in older adults. Protecting against this virus is an important consideration for many individuals. Medicare Part D, which provides prescription drug coverage, plays a significant role in ensuring access to important vaccines, including the RSV vaccine.
Medicare Part D Coverage for RSV Vaccine
Medicare Part D plans now cover the RSV vaccine. This expanded coverage, effective January 1, 2023, stems from the Inflation Reduction Act of 2022. This legislation eliminated out-of-pocket costs and deductibles for adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) and covered under Medicare Part D.
Since the ACIP recommends the RSV vaccine for adults aged 60 and older, Medicare Part D plans cover its full cost. This coverage applies across all Medicare Part D plans, ensuring broad access. Medicare Part D specifically covers this vaccine, distinguishing it from vaccines covered under Medicare Part B, such as flu shots or COVID-19 vaccines.
Understanding Your Part D Plan and Costs
While the RSV vaccine is covered without a deductible or copayment under Medicare Part D, your plan’s monthly premium still applies and must be paid to maintain coverage. The specific premium amount varies by plan.
Medicare Part D plans typically involve different coverage phases for other prescription drugs: a deductible, initial coverage, and catastrophic coverage phase. During the deductible phase, you pay the full cost of prescriptions until meeting your plan’s deductible. After, the initial coverage phase begins where your plan shares costs, and you pay a copayment or coinsurance.
The RSV vaccine is exempt from these cost-sharing phases, meaning it does not count towards your deductible or incur copayments or coinsurance. Beginning in 2025, a new $2,000 annual cap on out-of-pocket costs for prescription drugs will be implemented for Medicare Part D enrollees. This cap does not affect the no-cost RSV vaccine.
Accessing the RSV Vaccine
Once you have Medicare Part D coverage, obtaining the RSV vaccine is straightforward. It is typically administered at local pharmacies and doctor’s offices. Call ahead to confirm the location has the vaccine in stock and accepts your Medicare Part D plan.
When vaccinated, provide your Medicare card and Part D plan information. This allows the provider to bill your plan directly. If an out-of-network provider administers the vaccine, they may bill you directly; you would then submit the receipt to your Part D plan for reimbursement.
Other Ways to Get the RSV Vaccine
For individuals without a standalone Medicare Part D plan, alternative avenues for RSV vaccine coverage exist. Many Medicare Advantage (Part C) plans include prescription drug coverage (MAPD plans), which also cover the RSV vaccine. If you have a Medicare Advantage plan, verify its drug coverage and how it covers recommended vaccines.
State-specific programs or manufacturer patient assistance programs may offer support for vaccine costs. These programs provide options for those without Part D coverage or facing financial hardship. Individuals without Part D should contact their insurance provider or local health department for information on available resources.