Medicare Does Not Cover RSV Vaccines For These Vulnerable Groups

Medicare Does Not Cover RSV Vaccines For These Vulnerable Groups
Medicare Does Not Cover RSV Vaccines For These Vulnerable Groups | Image Credit:

Due to a loophole that means it’s not covered by all Medicare plans, certain elderly and pregnant people—among the most susceptible to respiratory syncytial virus (RSV)—must pay out of pocket (up to $300) for an RSV vaccination this year.

Important Information

  • The respiratory syncytial virus (RSV) mostly affects older adults and young children. Two vaccinations have been licensed by the Food and Drug Administration to protect older adults from RSV, while another is available to newborns through their expectant mothers.
  • Medicare Part D provides coverage for vaccinations as prescription medications, including the RSV vaccine (as well as the shingles and hepatitis A vaccines), albeit there may be an administrative cost.
  • However, according to statistics from the health policy research group KFF, some 16 million Medicare users aren’t enrolled in Part D, which means they must pay for the RSV vaccination out of pocket, which can leave some patients with a $330 charge, as reported by the New York Times.
  • Conversely, Part B, which pays for all vaccination expenses, including vaccine administration fees, covers the cost of a number of widely used vaccinations, including the flu and COVID vaccines.
  • Vaccination providers are paid under Part B but not Part D, so they direct patients with Part D coverage to pharmacies so they may pay for the RSV vaccination out of pocket. However, some patients stop receiving the vaccine at that point. This presents challenges even for people who have signed up for Part D.


Open enrollment periods are the only times when Medicare beneficiaries can add, remove, or transfer Part D plans. All beneficiaries have an open enrollment period from October 15 to December 7 2023, but coverage doesn’t start until January 1, 2024. There is an enrollment period for those in Medicare Advantage Programs from January 1 to March 31 2024, or during the first three months of receiving Medicare. For this, Part D coverage begins on the first of the next month. Plans can be changed by individuals who have experienced significant life events, such as relocating to a new residence or losing coverage, during a variable special enrollment period.

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2.1 million. The number of hospitalisations for RSV among children under five in the United States is around five times a year, as reported by the Centres for Disease Control and Prevention. In persons 65 years of age and older, it results in up to 160,000 outpatient visits. Every year, RSV causes between 6,000 and 10,000 fatalities in the elderly and between 100 and 300 in children under the age of five.


Richard Hughes IV, a vaccine law specialist with the firm Epstein Becker Green and a former vice president of public policy at Moderna, told the New York Times that “this is just the result of poor policy making.”

“It’s really not good that vaccines are fragmented; I believe that all vaccines should be available in all care settings.”


The FDA authorised RSV vaccinations by Pfizer and GlaxoSmithKline earlier this year for those 60 years of age and above. These vaccines have demonstrated up to 94% efficacy in avoiding serious disease. August saw the approval of Pfizer’s RSV vaccination for newborns, which is given to expectant mothers as an injection. The vaccine demonstrated 82% efficacy in avoiding severe sickness.


By the time they turn two, almost every kid will have experienced an RSV illness; however, most infections resolve on their own, according to the CDC.