If you're enrolled in Medicare, you'll be pleased to know that Medicare covers the RSV vaccine cost-free under Part D. This expanded coverage is a recent development, thanks to the Inflation Reduction Act (IRA), signed into law in August 2022. Alongside improvements such as enhanced benefits and lower drug costs, the IRA significantly bolsters vaccine coverage (effective January 1, 2023), ensuring greater access to essential preventive measures for Medicare beneficiaries.
Let’s discuss the RSV vaccine and how Medicare can help cover it.
Before we move forward, let's define Respiratory Syncytial Virus to understand what we’re discussing: RSV is a common respiratory virus with seasonal circulation typically starting in the fall each year. In otherwise healthy individuals, RSV infections often resemble the common cold. Signs of RSV infection can manifest as a runny nose, reduced appetite, coughing, sneezing, fever, or wheezing.
However, in vulnerable populations such as infants, older adults, and those with weakened immune systems, the virus can lead to more severe respiratory problems, including bronchiolitis, pneumonia, and lower respiratory tract disease (LRTD). Each year, RSV causes approximately 60,000-160,000 hospitalizations in adults aged 65 and older in the US.
In May 2023, a breakthrough occurred when the U.S. Food and Drug Administration (FDA) gave approval for the first-ever RSV vaccine, Arexvy. The CDC suggests that individuals aged 60 years and older may consider receiving a single dose of the RSV vaccine following discussions with their healthcare provider.
As you might know, Original Medicare is a comprehensive healthcare program consisting of two parts: Part A and Part B. Part A focuses on hospital-related services, addressing needs such as inpatient hospital stays, skilled nursing facility care, and hospice care. On the other hand, Part B is mainly for the purpose of outpatient and medical services, including preventive services, doctor visits, and select home health care needs.
Medicare Part B plays a crucial role in preventative services, covering certain vaccines to help safeguard your health. It covers vaccinations like COVID-19, flu, pneumococcal diseases, and hepatitis B. However, you must know that the RSV vaccine doesn't have coverage under Medicare Part B.
The RSV vaccine has coverage under Medicare Part D, which provides you with protection against this respiratory virus. Should your doctor or pharmacy attempt to bill you for the RSV vaccine, and you have Medicare Part D, make sure to call 1-800-MEDICARE (1-800-633-4227) immediately for assistance.
It's crucial to note that vaccine availability in Part D is subject to approval by the Advisory Committee on Immunization Practices (ACIP). These approved vaccines may change over time, so you should regularly check the complete list of ACIP recommendations on the CDC website.
Medicare Advantage, an approved plan by Medicare, is provided by private companies, presenting an alternative to Original Medicare for health and drug coverage. These comprehensive plans (bundled plans) that encompass Part A, Part B, and typically Part D.
When you go to in-network providers and pharmacies, Medicare Advantage plans with Part D included fully cover the cost of the RSV vaccine for you at no expense. It's important to note that if your Medicare Advantage plan lacks a Part D component, it won't cover the RSV vaccine.
If you have drug coverage outside of Medicare, such as coverage from an employer or union, review the coverage rules pertaining to the RSV vaccine. Given that the vaccine is relatively new, it may not be one of the covered drugs in your insurance plan. Therefore, confirm the coverage details with your provider before scheduling an appointment, as the vaccine may not be explicitly listed yet.
If you don't have Part D, getting the RSV vaccine might mean paying out-of-pocket. The price per shot can range from $180 to $295.
You can now obtain the RSV vaccine at major retail pharmacies across the US, making it easily accessible for older adults. You can usually receive vaccines at various locations, including drugstores, community health centers, senior centers, and community-based organizations. In some cases, your doctor's office may also offer vaccinations.
You can also contact your state's health department and the State Health Insurance Assistance Program (SHIP) staff for additional guidance on vaccines and their availability in your area.
Medicare is specific in how it covers the RSV vaccine. Part D will pay for the entire amount, whereas a Medicare Advantage plan may cover some or all the costs. Should you have questions about Medicare and vaccinations, our team is ready to help. Contact us today!
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