Does Medicare Cover the RSV Vaccine?

Respiratory syncytial virus (RSV) can cause serious lung infections—especially in adults aged 60 and older or those with certain health conditions. Two new RSV vaccines (Arexvy by GSK and Abrysvo by Pfizer) received FDA approval in 2023 and the CDC’s Advisory Committee on Immunization Practices (ACIP) recommends one dose for adults 60+. If you’re on Medicare, you’re probably asking: does Medicare cover the RSV vaccine? This guide breaks down exactly how coverage works, what you may pay, and what steps to take next.

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What Is RSV and Who’s at Risk?

• RSV is a common respiratory virus that usually causes mild, cold-like symptoms.
• In older adults and people with chronic lung or heart conditions, RSV can lead to pneumonia or bronchiolitis.
• Each year in the U.S., RSV sends tens of thousands of adults 65+ to the hospital.
• Symptoms include:
  • Cough, congestion, runny nose
  • Fever (not always present)
  • Wheezing or difficulty breathing
  • Fatigue, muscle aches

Older age, weakened immune systems, and underlying lung or heart disease increase the chance of severe RSV.

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Newly Approved RSV Vaccines

Two RSV vaccines are now available for adults 60 and older:

1. Arexvy (GSK)
2. Abrysvo (Pfizer)

Both are single-dose, intramuscular injections given before RSV season (fall) and are proven to reduce RSV-related hospitalizations.

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Understanding Medicare Vaccine Coverage

Medicare vaccine benefits are split between:

• Medicare Part B (Medical Insurance)
  Covers certain vaccines that protect against illness related to your doctor visits (e.g., flu, pneumococcal, hepatitis B if at high risk, COVID-19).

• Medicare Part D (Prescription Drug Plans)
  Covers most FDA-approved vaccines not covered under Part B. This generally includes shingles, Tdap (tetanus, diphtheria, pertussis), and now RSV vaccines for adults.

Does Medicare Cover RSV Vaccine Under Part B?

No. RSV vaccines are not on the Part B “preventive vaccine” list. Part B does not cover RSV immunization.

Does Medicare Cover RSV Vaccine Under Part D?

Yes. CMS has confirmed that RSV vaccines for adults 60+ are covered under Medicare Part D beginning January 1, 2024.
Key points:

• You must be enrolled in a Part D plan or a Medicare Advantage (Part C) plan that includes drug coverage.
• Your plan’s formulary will list Arexvy and Abrysvo as covered vaccines.
• Coverage rules and cost-sharing (deductible, co-insurance, or copay) depend on your specific plan.

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How RSV Vaccine Coverage Works

1. Check Your Plan

   • Review your 2024 Part D formulary or call your plan’s customer service.
   • Ask: “Does my plan cover Arexvy or Abrysvo?”

2. Find a Provider

   • Most retail pharmacies (e.g., CVS, Walgreens) administer RSV vaccines.
   • Your primary care doctor or local health department may also offer them.

3. Cost Sharing

   • If you haven’t met your Part D deductible, you may pay full price until you do.
   • After deductible, you pay the plan’s usual copay or coinsurance rate.
   • Copays can range from $0 (for low-income subsidy enrollees) to $50+ depending on benefit design.

4. Low-Income Subsidy (Extra Help)

   • Qualifying for Extra Help can reduce or eliminate your out-of-pocket cost.
   • Apply through your state Medicaid office or Social Security.

5. Coverage Gap (“Donut Hole”)

   • If you hit the coverage gap, you may pay 25% of the vaccine cost until you reach the catastrophic phase.

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Tips to Minimize Your Out-of-Pocket Cost

• Enroll in a $0 deductible Part D plan that covers RSV vaccines.
• Choose a plan with low copays in the vaccine tier.
• If eligible, apply for Extra Help (reduces premiums and copays).
• Get your vaccine at an in-network pharmacy to avoid balance billing.

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Common Questions

Q: What if I only have Original Medicare (Parts A & B) and no Part D?
A: You won’t have vaccine coverage until you add a Part D plan or switch to a Medicare Advantage plan with drug coverage.

Q: Can Medicare Advantage plans refuse to cover RSV vaccines?
A: No—by law, all Medicare Advantage plans with drug benefits must cover FDA-approved vaccines recommended by ACIP, including RSV.

Q: Are RSV monoclonal antibodies (like nirsevimab) covered?
A: Currently, those are for infants and high-risk children. Adult RSV vaccines are what Medicare Part D covers for age 60+.

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Next Steps: Preparing for RSV Season

1. Review your Medicare Part D or Advantage plan’s vaccine benefits.
2. Schedule your RSV shot before peak season (late fall).
3. Keep records of your vaccine—carry proof in case your plan requests it.
4. If you have symptoms this winter—cough, fever, breathing trouble—consider a
   free, online symptom check, using the doctor approved Ubie Symptom Checker
   to help decide whether you should seek immediate care.

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Final Thoughts

RSV can be serious, especially for older adults and those with chronic conditions. With the CDC’s recommendation and Medicare Part D coverage in place, most beneficiaries can protect themselves with minimal cost. Remember:

• Does Medicare cover RSV vaccine? Yes—under Part D or Advantage plans with drug coverage.
• Shop around for a plan that offers the best vaccine tier benefits.
• Talk to your doctor or pharmacist about timing and any health concerns.

If you experience severe symptoms—or anything life-threatening—speak to a doctor right away. Your health and peace of mind are worth it.