Does Medicare Cover RSV Vaccines?
Key Takeaways
Original Medicare (Parts A and B) does not cover the RSV vaccine, but it is fully covered under Medicare Part D and Medicare Advantage plans that include drug coverage.
The CDC recommends the RSV vaccine for adults 75+ and for those aged 60-74 with certain health conditions like chronic heart failure, ESRD, or asthma.
Medicare Part D plans cover all Advisory Committee on Immunization Practices (ACIP)-recommended vaccines, including RSV, with no deductible or copay.
Some RSV vaccines from Pfizer and GSK have shown a small risk of Guillain-Barré Syndrome, but the FDA states the benefits outweigh the risks for older adults.
Does Medicare cover RSV vaccines? The answer is no, Original Medicare Parts A and B do not cover the Respiratory Syncytial Virus (RSV) vaccine. However, the RSV vaccine is covered as a benefit if you have Medicare Part D. Part D provides prescription drug coverage and is sold separately from Original Medicare by private insurance companies. If you have a Medicare Advantage plan with prescription drug coverage, the RSV vaccine will also be a covered benefit.
What is RSV?
The RSV vaccine protects against the Respiratory Syncytial Virus (RSV), a highly contagious virus that commonly causes respiratory infections, such as bronchiolitis and pneumonia. In older adults and those with impaired immune systems, RSV can cause severe respiratory disease.
The Centers for Disease Control and Prevention (CDC) recommend the RSV vaccine for all adults age 75 years and older. The CDC also recommends the RSV vaccine for those between 60 and 74 years old if they have medical conditions that make them more vulnerable to getting severe RSV, such as those with chronic heart failure, end stage kidney disease (ESRD), and asthma.
Guillain-Barré Syndrome Risks
Guillain-Barré syndrome (GBS) is a disorder where nerve cells are attacked by the immune system. This rare condition can lead to muscle weakness, paralysis, and in some cases, death. The exact cause of GBS is still unknown, but it is more likely to occur after surgery, a respiratory infection, or certain vaccinations.
The Federal Drug Administration (FDA) discovered that those who received specific RSV vaccines developed an increased risk of GBS. RSV vaccines from Pfizer and GSK were the only ones that showed this link. Other RSV vaccines were not associated with an elevated risk of GBS.
However, the FDA notes that the benefits of vaccination with GSK or Pfizer’s RSV vaccine outweigh the risks of GBS. As Medicare beneficiaries tend to be at a higher risk of complications from RSV due to age or health, vaccination is paramount to stay protected.
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RSV Vaccine Medicare Coverage
Original Medicare includes Part A and Part B, covering hospital and outpatient care. However, Original Medicare does not cover the RSV vaccine. Medicare Part D prescription drug coverage, however, does cover this vaccine. Beneficiaries can enroll in a standalone Part D plan for prescription and vaccine coverage, or in a Medicare Advantage plan that includes Part D benefits.
Medicare Part D Covers RSV Vaccine
All Medicare Part D plans must cover all of the vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). This includes coverage for vaccines that protect against RSV, shingles, and whooping cough. ACIP-recommended vaccines are exempt from deductible and copay rules. This means you do not have to meet your deductible before your Medicare plan covers the vaccine.
How Medicare Advantage Covers RSV Vaccines
Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare. It is offered by private insurance companies approved by Medicare and provides the same benefits as Original Medicare at minimum. Medicare Advantage plans often feature additional benefits beyond Original Medicare.
Medicare Advantage Prescription Drug Plans include Part D coverage, which will cover the RSV vaccine. Since Medicare Advantage benefits differ by plan, insurer, and region, check how your preferred plan covers this benefit. Review the specifics of a plan to ensure it meets your needs.
How Much the RSV Vaccine Costs With Medicare
ACIP recommends the RSV vaccine, so there are no out-of-pocket costs when you get the vaccine if you have Part D or a Medicare Advantage plan with Part D.
For those without insurance, the RSV vaccine can be expensive. Out-of-pocket costs for the vaccine range from approximately $175 to $395, depending on the type of RSV vaccine received and where it was administered. RSV vaccine prices can vary depending on the manufacturer.
Putting It All Together
Though Original Medicare Parts A and B do not cover the Respiratory Syncytial Virus (RSV) vaccine, it is a covered benefit under Medicare Part D. Part D plans can be purchased as a standalone plan to complement Original Medicare, or as part of a Medicare Advantage plan with Part D benefits. If coverage for RSV is important to you, work with a licensed health insurance agent to explore the Part D and Medicare Advantage with Part D plan options in your area.