Some health insurance plans do not cover the new RSV vaccines

Lucien Daug, 63, likes to get his flu shot early each year before he’s among the college students at the University of Washington Tacoma, where he teaches law and ethics. This year, he decided to get the new RSV vaccine at the same time, so he made an appointment earlier this month to get both doses at his local Walgreens in Gig Harbor, Washington.

But when he got to the pharmacy, he was told the RSV vaccine was not covered by his insurance company, Anthem Blue Cross Blue Shield. Out-of-pocket cost? About $330.

“I am in very good health, I have no pre-existing conditions, and I am willing to take my chance,” Mr. Doge said, adding, “I wouldn’t pay that much money.” Pay out of his pocket.”

When the Food and Drug Administration approved two RSV vaccines earlier this year for adults ages 60 and older, they were heralded as a potentially life-saving breakthrough. Each year, between 6,000 and 10,000 people in the United States over the age of 65 die from respiratory syncytial virus, and between 60,000 and 160,000 are hospitalized with it. The two vaccines, made by Pfizer and GSK, are more than 80 percent effective in preventing lower respiratory symptoms, such as coughing and shortness of breath, associated with respiratory syncytial virus infection.

But right now, some insurance plans don’t cover the cost, forcing people to pay hundreds of dollars if they want protection.

Amanda Jaffe, 69, went to her local Safeway pharmacy in Helena, Mont., to get her RSV vaccine last week in anticipation of traveling cross-country next month. Ms. Jaffe said that when the pharmacist told her the shot was not covered under Medicare Part B, “he seemed just as surprised as I was”. Upon hearing the price (over $300), Mrs. Jaffe thought “that’s ridiculous” and left without getting it.

Many common vaccines, including influenza and COVID-19 vaccines, are included in Medicare Part B, which provides medical coverage. However, the respiratory syncytial virus (RSV) vaccines, as well as a few others, including the shingles vaccine, are covered under Medicare Part D, which pays for prescription drugs. As a result, those enrolled in Medicare without a Part D plan—nearly 16 million people—may have to pay for the RSV vaccine out of pocket depending on their non-Medicare prescription drug coverage.

Richard Hughes IV, a Vaccine law expert at Epstein-Baker Green and former vice president of public policy at Moderna Inc. “I think vaccines, all vaccines, should be available in all settings of care, so that fragmentation is really not good.”

A spokeswoman for the Centers for Medicare and Medicaid Services confirmed in an email to The New York Times that RSV vaccines should be freely available to people with Medicare Part D. And if people are told otherwise when they go to get the vaccine, they will. Call 1-800-MEDICARE for assistance.

For people with private insurance, like Mr. Dougie, the situation is less clear. Under the Affordable Care Act, private health insurance companies must cover the cost of preventive care, including vaccines recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. However, the ACIP’s recommendations for the RSV vaccine put the final decision in the hands of individuals in consultation with their physicians: official guidance It says that anyone 60 or older “may receive a single dose of respiratory syncytial virus (RSV) vaccine, using combined clinical decision making.”

Mr Hughes said private health insurers have sometimes used such language as a loophole to get away with paying for vaccines, claiming that CDM does not qualify as an official ACIP recommendation.

Another rationale is that the RSV vaccine has not yet been included in the CDC’s annual report Vaccination schedule for adultswhich may not be updated until early 2024. In an email to The New York Times, a spokeswoman for Blue Cross Blue Shield wrote that until RSV “appears on the immunization schedule, it is up to each BCBS plan to decide whether it wants it for coverage.” “

Other private insurance companies already cover the cost. Teresa Schultes, 65, of New Berlin, Wisconsin, said she had no problem getting the vaccine at Walgreens, and it was free using her Medicare Advantage plan through United Healthcare.

Because policies differ between health insurers, it’s a good idea to call to check if your plan covers the cost of the vaccine before making an appointment to get the vaccine.