A Quick Guide to the RSV Vaccine and Medicare Coverage

RSV presents a health risk to certain older adults, leading the CDC to recommend vaccination and Medicare to ensure coverage of RSV vaccines under Part D.

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RSV Risks, Vaccination Recommendations, and Medicare Coverage Details

• RSV usually causes mild symptoms in most people, but it can lead to serious complications, especially in individuals aged 60 and older and those with chronic heart or lung conditions.
• The CDC recommends vaccination for high-risk groups. Two vaccines, Arexvy and Abrysvo, have been approved by the FDA for individuals aged 60 and older and protect for two years.
• Medicare covers the RSV vaccine under Part D, with coverage details varying among Medicare Advantage plans.

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RSV, or respiratory syncytial virus, is a common respiratory infection that typically causes mild, cold-like symptoms in most individuals. While the virus usually resolves within a week, some groups are at higher risk of severe complications.

Fortunately, the Food and Drug Administration has approved two vaccines to help protect against RSV: Arexvy by GlaxoSmithKline and Abrysvo by Pfizer. The Centers for Disease Control and Prevention recommends vaccination for higher-risk populations, especially those aged 60 and older.

Those over 60 should be very concerned about contracting RSV," says Dr. Roopa Anmolsingh, a geriatrician at the Cleveland Clinic’s Center for Geriatric Medicine in Cleveland, Ohio. "Due to RSV, around 6,000 to 10,000 older adults die annually. Older persons also often have chronic conditions – such as chronic obstructive pulmonary disease (COPD), asthma, and heart disease – which may worsen with severe RSV."

Given the seriousness of the illness in certain populations, it is crucial to ensure that people are protected from RSV and have access to the vaccine through their insurance.

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Medicare Coverage

The RSV vaccine is covered under Medicare Part D (drug coverage) with no out-of-pocket costs for the vaccine itself but always check with your plan first.

While Medicare covers vaccines for the flu, pneumonia, hepatitis B, and COVID-19 under Part B (medical insurance) when treating disease exposure, Part D covers all vaccines recommended by the Advisory Committee on Immunization Practices, except those covered by Part B.

Any vaccine administration fee at the time of service is reimbursable through Medicare. If you are informed otherwise when you go to get the vaccine, call 1-800-MEDICARE for assistance.

Medicare Advantage plans (Part C) usually cover the RSV vaccine, but coverage details may vary by plan. Contact your Medicare Advantage plan or review the summary of benefits before making an appointment to understand what is covered. They can provide information on any associated costs or copayments, as well as where to receive the vaccine within the plan's network.

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Conclusion

RSV commonly appears as a mild illness similar to a cold but can pose significant health risks, particularly for individuals aged 60 and older and those with chronic heart or lung conditions. Hence, high-risk individuals must take preventive measures and safeguard themselves (and others) through vaccination.

If you have a Medicare Part D plan, you can receive the RSV vaccine. For Medicare Advantage plan members, RSV vaccines are likely covered, but benefits may vary among plans, so inquire with your plan about the inclusion of RSV vaccines.

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