Is the RSV Shot Covered by Insurance?

Respiratory Syncytial Virus (RSV) is a common respiratory virus that can cause severe illness, particularly in infants and older adults. With the RSV vaccine now available, many question the extent of insurance coverage. This article clarifies how RSV vaccine coverage operates and guides individuals in verifying their benefits.

Understanding RSV Vaccine Coverage

Many insurance plans, especially those compliant with the Affordable Care Act (ACA), cover preventive vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). The ACA mandates non-grandfathered health plans cover ACIP-recommended immunizations without cost-sharing. Eligible individuals typically face no copayments, coinsurance, or deductibles for these services when received from an in-network provider.

There are currently three FDA-approved RSV vaccines for adults aged 60 and older: Arexvy (GSK), Abrysvo (Pfizer), and mResvia (Moderna). Abrysvo is also approved for pregnant individuals between 32 and 36 weeks gestation to protect infants, and for adults aged 18-59 at increased risk. Arexvy is approved for adults aged 50-59 with increased risk for lower respiratory tract disease caused by RSV.

RSV vaccine coverage varies by insurance plan. Private insurance plans, including employer-sponsored and individual plans, follow ACIP recommendations for preventive services, though terms may differ. Medicare, a federal health insurance program, covers the RSV vaccine under Part D, which covers prescription drugs. Medicare beneficiaries with Part D coverage typically have no out-of-pocket costs for the RSV vaccine.

Medicaid covers ACIP-recommended vaccines, including the RSV vaccine, with no cost-sharing. TRICARE, the healthcare program for uniformed service members, retirees, and their families, covers RSV vaccines for specific populations based on CDC recommendations, including infants, children at increased risk, older adults, and pregnant individuals. TRICARE beneficiaries can receive these vaccines at no cost at military hospitals or clinics, TRICARE retail network pharmacies, or from TRICARE-authorized providers.

ACIP recommendations for age and risk groups influence coverage. ACIP recommends RSV vaccination for adults aged 75 and older, and for adults aged 60-74 with increased risk for severe RSV disease. The recommendation also includes adults aged 50-59 at increased risk for RSV-associated lower respiratory tract disease. Coverage aligns with these recommendations.

Coverage can depend on whether the vaccine is administered by an in-network or out-of-network provider. In-network services are typically covered at a higher rate or without cost-sharing for preventive services, while out-of-network services may incur higher out-of-pocket expenses or not be covered. Some insurance plans require prior authorization for the RSV vaccine. This process involves the healthcare provider obtaining approval from the insurance company before administering the vaccine, confirming its medical necessity and coverage.

Verifying Your Insurance Coverage

Before receiving the RSV vaccine, gather specific information for verification. You will need your insurance card, which contains your policy number, group number, and customer service phone number. Identify the specific RSV vaccine you intend to receive, such as Arexvy or Abrysvo, as coverage can depend on the brand.

Knowing the name and location of the healthcare provider or pharmacy where you plan to get the shot is beneficial. Prepare specific questions for your insurance provider: “Is the RSV vaccine [specific brand name] covered under my plan?”, “Is it covered at [specific provider/pharmacy]?”, “Are there any out-of-pocket costs, such as copayments, coinsurance, or deductibles?”, “Is prior authorization required for this vaccine?”, and “What is the CPT code for this vaccine and its administration?” Common CPT codes for RSV vaccines include 90678, 90679, and 90683, with administration codes like 90471 or 90472.

Once you have gathered the necessary information, verify your coverage. The most direct method is to call your insurance provider using the customer service number on your insurance card. When speaking with a representative, state your intent to confirm RSV vaccine coverage and provide your policy and group numbers. Be prepared to share the specific vaccine name and the location where you plan to receive it.

During the call, ask all prepared questions. Take detailed notes, including the date, time, representative’s name, and a reference number. This documentation is valuable if discrepancies arise later regarding coverage or billing. Many insurance companies offer online portals where members can access their benefits information.

These portals allow you to search for covered services, view your benefits summary, and estimate costs. While online tools provide a general overview, a direct phone call to a representative yields the most precise and current coverage details. You can also check with your healthcare provider’s office or the pharmacy where you plan to get the vaccine.

These entities can check insurance eligibility and benefits for specific services. However, while they assist, the responsibility for verifying coverage rests with the patient. Confirming coverage directly with your insurer minimizes unexpected out-of-pocket expenses.

Managing Costs Without Full Coverage

Even with broad insurance coverage for preventive services, the RSV vaccine may not be fully covered, leading to out-of-pocket expenses. These costs include deductibles (amounts paid before insurance covers services), copayments (fixed amounts paid for a covered service after deductible), and coinsurance (a percentage of the cost paid after meeting deductible).

If your RSV vaccine claim is denied, you have the right to appeal. The appeal process involves submitting a formal request to your insurance company, with supporting documentation from your healthcare provider. Understanding the specific reasons for the denial is the first step in an effective appeal.

Several resources can help manage vaccine costs if full insurance coverage is unavailable. Manufacturer patient assistance programs offer financial aid for their vaccines. Public health or patient advocacy organizations may have programs or information about financial assistance. Inquire about these options.

Comparing costs across different pharmacies or healthcare providers can lead to savings. The retail price of the RSV vaccine without insurance can range, with estimates around $350. Some pharmacies offer the vaccine at a lower price or have discount programs. Websites and applications providing prescription drug coupons, such as GoodRx, can help reduce the out-of-pocket cost.

If you anticipate out-of-pocket costs, discuss payment plans with your healthcare provider or pharmacy. Many providers work with patients to establish payment schedules. Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) are tools for covering out-of-pocket medical expenses, including vaccine costs. Contributions to these accounts are made with pre-tax dollars, resulting in tax savings. Using an HSA or FSA for the RSV vaccine allows payment with tax-advantaged funds.