Is the RSV Vaccine Covered by Medicare Part B?

Respiratory Syncytial Virus (RSV) is a common respiratory virus that typically causes mild, cold-like symptoms. However, for certain populations, particularly older adults, RSV can lead to more severe illness, including bronchiolitis and pneumonia, potentially requiring hospitalization. The development of RSV vaccines offers protection against serious complications, reducing the burden of severe RSV disease, especially among those most vulnerable.

Medicare Coverage for the RSV Vaccine

The RSV vaccine is covered for Medicare beneficiaries, though not under Medicare Part B as some might expect. Instead, coverage for the RSV vaccine falls under Medicare Part D, the prescription drug coverage portion of Medicare.

The reason for this coverage under Part D, and notably at no out-of-pocket cost, stems from the Inflation Reduction Act of 2022. This legislation mandated that all adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) of the CDC are covered without any deductible, copayment, or coinsurance for beneficiaries enrolled in a Medicare Part D plan. This provision eliminates financial barriers to receiving recommended vaccines.

Medicare Part B generally covers certain preventive vaccines like the flu shot, pneumonia vaccines, and the COVID-19 vaccine. However, the RSV vaccine is specifically designated under Part D because it is considered a prescription drug benefit.

Eligibility for the RSV Vaccine

The CDC and ACIP issue specific recommendations for who should receive the RSV vaccine. These guidelines are based on age and an individual’s risk factors for severe disease. A single dose of the RSV vaccine is recommended for all adults aged 75 and older.

For adults aged 50 to 74, the CDC recommends a single dose of the RSV vaccine if they are at increased risk of severe RSV disease. This increased risk is associated with certain underlying chronic medical conditions. Examples include:
Chronic cardiovascular disease
Chronic lung or respiratory disease
End-stage renal disease
Diabetes with complications
Neurologic or neuromuscular conditions that impair airway clearance
Chronic liver disease
Living in a nursing home

How to Access Your RSV Vaccine

Medicare beneficiaries can receive the RSV vaccine at several locations. The vaccine can be obtained at a doctor’s office, a local pharmacy, or other clinical settings. Many pharmacies administer vaccines.

When visiting a provider or pharmacy, bring your Medicare card, especially your Part D information, as Part D covers the RSV vaccine. The administering provider or pharmacy will bill your Medicare Part D plan directly for the vaccine. This direct billing ensures you receive the vaccine with no out-of-pocket costs, consistent with coverage rules.

If a provider is out-of-network for your Part D plan, they might bill you directly. In such cases, you can submit the receipt to your Part D plan for reimbursement. However, situations requiring upfront payment and subsequent reimbursement are rare, as Part D plans are required to provide convenient access to covered benefits.

Medicare Advantage and Other Coverage Scenarios

For beneficiaries enrolled in a Medicare Advantage (Part C) plan, coverage for the RSV vaccine is also provided. Medicare Advantage plans are private health insurance plans that contract with Medicare to provide Part A and Part B benefits, and many also include Part D prescription drug coverage. If your Medicare Advantage plan includes prescription drug coverage, it is required to cover the RSV vaccine at no cost, mirroring Original Medicare Part D.

It is important to confirm that your specific Medicare Advantage plan includes prescription drug coverage, as not all plans do. If your Medicare Advantage plan does not include Part D benefits, you would need a separate standalone Medicare Part D plan for RSV vaccine coverage. Medicare Part D plans cover all ACIP-recommended vaccines, including RSV, without deductibles or copays.

Medicare Part D is the primary avenue for vaccine coverage, unless a vaccine is explicitly covered by Part B (like flu or pneumonia shots). Therefore, if you only have Original Medicare (Parts A and B) without a separate Part D plan or a Medicare Advantage plan with drug coverage, the RSV vaccine would not be covered. Private health insurance plans outside of Medicare are also required to cover ACIP-recommended vaccines without cost-sharing, though specific details should be verified with the individual plan.