Is the RSV Shot Covered by Medicare?

Respiratory Syncytial Virus (RSV) is a common respiratory illness that typically causes mild, cold-like symptoms. While many individuals recover quickly, RSV can lead to more serious conditions such as pneumonia and bronchitis in certain populations. Recent medical advancements have made vaccines available to help protect specific groups from severe RSV illness.

Medicare Coverage for the RSV Shot

The Respiratory Syncytial Virus (RSV) shot is covered by Medicare, primarily through its prescription drug coverage. Medicare Part D, which includes stand-alone prescription drug plans, is responsible for covering the RSV vaccine. Original Medicare, specifically Part A (Hospital Insurance) and Part B (Medical Insurance), generally does not cover the RSV shot.

Medicare Advantage Plans (Medicare Part C) that include prescription drug coverage, often referred to as Medicare Advantage Prescription Drug plans (MAPDs), also cover the RSV vaccine. These plans are required to provide at least the same level of coverage as Original Medicare, and in this case, they integrate the Part D benefit. Beneficiaries enrolled in a Medicare Advantage plan should confirm their plan includes drug coverage to ensure the vaccine is covered.

Eligibility for Coverage

Medicare coverage for the RSV shot is determined by specific eligibility criteria, largely based on recommendations from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). The ACIP advises that adults aged 60 and older are candidates for the RSV vaccine.

Specifically, all adults aged 75 and older are recommended to receive the RSV vaccine. Adults aged 60 to 74 years who have certain medical conditions that increase their risk of severe RSV disease are also eligible for coverage. These conditions can include chronic heart or lung disease, weakened immune systems, or other specified health issues.

Understanding Your Costs

Medicare beneficiaries typically face no out-of-pocket costs for the RSV vaccine. The Inflation Reduction Act, effective January 1, 2023, eliminated deductibles, copayments, and coinsurance for all adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) and covered under Medicare Part D.

This means that if you have Medicare Part D or a Medicare Advantage plan with prescription drug coverage, the RSV shot should be provided to you at no cost. While the typical cost of the RSV vaccine without insurance can range from approximately $175 to $550, this cost is waived for eligible Medicare beneficiaries. It is always advisable for beneficiaries to confirm coverage details with their specific Medicare plan provider to avoid any unexpected charges.

Getting the RSV Shot

Medicare beneficiaries can obtain the covered RSV shot at various convenient locations. Common sites for vaccination include local pharmacies, doctor’s offices, and community health clinics. Many healthcare providers are equipped to administer the vaccine and process the Medicare coverage.

When going to receive the shot, it is helpful to bring your Medicare card and any insurance plan information, especially if you are enrolled in a Medicare Advantage Plan. For those with Medicare Advantage, contacting your plan beforehand can help confirm where you can receive the shot with no out-of-pocket costs. It is generally safe to receive the RSV shot alongside other vaccines, such as the flu shot or COVID-19 vaccine.