Does Medicare cover the RSV vaccine?

Amid COVID scares and serious flu complications, it’s natural to be curious about the new RSV vaccine. RSV, or Respiratory Syncytial Virus, is a respiratory virus that causes cold-like symptoms. As you may already know, respiratory illnesses are especially dangerous for people who are 65 and older. Up to 10,000 people in the US above the age of 65 die from RSV every year, and between 60,000 to 160,000 older adults have been hospitalized because of it. You can protect yourself from this potentially deadly virus with an RSV shot.

Fortunately, Medicare prescription drug coverage (Part D) covers the RSV vaccine. We’ll explore how Medicare covers the shot and what to do if it isn't on your plan’s formulary in this article.

Key takeaways:

• RSV, or Respiratory Syncytial Virus, is a respiratory virus that causes cold-like symptoms.

• Medicare prescription drug insurance (Part D) covers 100% of the costs of the RSV vaccine. 

• The RSV shot costs about $330 without insurance.

What is RSV?

RSV is a respiratory virus that affects your lungs and respiratory tract. Like the flu, RSV is very common—most children have had RSV by the age of two. Symptoms of the virus are similar to a cold, including:

• Dry cough, sneezing, runny nose

• Low fever

• Sore throat

• Headache

Because early symptoms are similar to a cold, it’s hard to know when you have RSV unless your condition worsens. In severe cases, which are more likely if you’re 65 and older, RSV can cause infection to spread to the lower respiratory tract. This can lead to pneumonia or bronchiolitis, where a person could experience:

• A more severe cough

• High fever

• Wheezing 

• Rapid or difficulty breathing

• Skin turning blue because of the lack of oxygen (called cyanosis)

What’s more, Covid can lower your immunity and increase the likelihood of you getting RSV or the flu, which can make the situation much worse. You don’t have to worry about getting the RSV shot with other vaccines—it’s perfectly safe to get the Covid-19, flu, and RSV shot at the same time.

How does the RSV vaccine work?

Similar to other vaccines, the RSV shot works by putting an inactive RSV protein into your body. This protein then attaches to your cells and signals to your immune system to react when the real RSV virus enters your system.

Additional information about the RSV vaccine

In 2023, the Food and Drug Administration (FDA) approved a few different RSV vaccines for infants, toddlers, pregnant women, and older adults—groups that are the most likely to get sick from the virus. These vaccines are especially important during the times when RSV is at its peak, usually in the fall and winter.

Symptoms of the RSV vaccine

Symptoms from the shot are pretty standard. You may experience pain, redness, and swelling where your provider injects the vaccine. Reports also show that sometimes you may experience symptoms similar to the Covid vaccine like fatigue, fever, headache, nausea, and diarrhea.

Does Medicare cover the RSV vaccine?

Yes, Medicare prescription drug insurance (Part D), covers the RSV vaccine. Part D covers any vaccine that the Advisory Committee on Immunization Practices (ACIP) approves, including the RSV shot. With Medicare Part D, you’ll pay absolutely nothing out-of-pocket (no copayment or deductible) for any vaccine recommended by the ACIP. 

Important notes:

The drugs that Part D covers vary from plan to plan. The RSV shot may not already be on the list of drugs (called a formulary) provided by your insurance. If this is the case, you can contact your insurance provider and ask for coverage exception. If you pay for the shot yourself, you can also contact your plan to get reimbursed. 

Where can you get the RSV vaccine?

Your local pharmacy, doctor’s office, health clinic, or other health facility can give you the RSV vaccine. Get in touch with your insurance company to find the nearest place you can get the shot.

How much does the RSV vaccine cost?

It can be helpful to know how much the RSV vaccine costs if you don’t have Medicare Part D or if you have private insurance that doesn’t cover the shot. If the RSV vaccine isn’t covered with your insurance, it can cost you upwards of $330. 

While the cost is high without insurance, the vaccine can prevent serious complications, especially if you have a weaker immune system or have a hematologic disorder like sickle cell disease. Our licensed Advisors can help you sign up for Medicare or help you understand and address gaps in your coverage. Call 855-900-2427 or schedule a chat today for free, personalized Medicare advice.