Lucien Dhooge, 63, likes to get his flu shot early every year before being around college students at the University of Washington Tacoma, where he teaches law and ethics. This year, he decided to get the new vaccine for respiratory syncytial virus at the same time, so he made an appointment earlier this month for both shots at his local Walgreens in Gig Harbor, Wash.
But when he arrived at the pharmacy, he was told that the R.S.V. vaccine wasn’t covered by his insurance provider, Anthem Blue Cross Blue Shield. The out-of-pocket cost? About $330.
“I’m in pretty good health, I don’t have any pre-existing conditions and I’m willing to just take my chances,” Mr. Dhooge said, adding, “I’m not going to pay that kind of money out of pocket.”
When the Food and Drug Administration approved two R.S.V. vaccines earlier this year for adults aged 60 and up, they were heralded as a potentially lifesaving breakthrough. Every year, between 6,000 and 10,000 people in the United States over the age of 65 die from R.S.V., and 60,000 to 160,000 are hospitalized because of it. The vaccines, which are manufactured by Pfizer and GSK, are both over 80 percent effective at preventing lower respiratory symptoms, such as cough and shortness of breath, associated with an R.S.V. infection.
But currently, some insurance plans aren’t covering the cost, forcing people to pay hundreds of dollars if they want to be protected.
Amanda Jaffe, 69, went to her local pharmacy at the Safeway in Helena, Mont., to get the R.S.V. vaccine last week in anticipation of flying across the country next month. When the pharmacist told her the shot wasn’t covered by her Medicare Part B plan, “he seemed as surprised as me,” Ms. Jaffe said. Upon hearing the price (over $300), Ms. Jaffe thought “that’s ridiculous” and left without getting it.
Several common vaccines, including those for the flu and Covid-19, are included under Medicare Part B, which provides medical coverage. However, the R.S.V. vaccines, as well as a few others, including the vaccine for shingles, are covered under Medicare Part D, which pays for prescription drugs. As a result, Medicare enrollees without a Part D plan — roughly 16 million people — may have to pay for the R.S.V. vaccine out of pocket depending on their non-Medicare prescription drug coverage.
“This is just the result of poor policymaking,” said Richard Hughes IV, a vaccine-law expert at the firm Epstein Becker Green and the former vice president of public policy at Moderna. “I think that vaccines, all vaccines, should be accessible in all settings of care, and so this fragmentation is really just not good.”
A spokeswoman for the Centers for Medicare & Medicaid Services confirmed in an email to The New York Times that the R.S.V. vaccines should be available free of charge to people with Medicare Part D. If people are told otherwise when they go to get the vaccine, they should call 1-800-MEDICARE for assistance.
According to a Medicare fact sheet, even if a vaccine isn’t included on your Part D plan’s list of covered drugs, the plan must still pay for it if your doctor prescribes it. And per the Inflation Reduction Act of 2022, patients with Medicare drug plans no longer have to pay any out-of-pocket expenses for federally recommended adult vaccines. If you’re charged a fee, your Part D plan should reimburse you.
For people with private insurance, like Mr. Dhooge, the situation is less clear. According to the Affordable Care Act, private health insurers 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 A.C.I.P. recommendations for the R.S.V. vaccine put the final decision in the hands of individuals in consultation with their doctors: The official guidance says that anyone aged 60 years or older “may receive a single dose of R.S.V. vaccine, using shared clinical decision-making.”
Private health insurers have sometimes used this language as a loophole to get out of paying for vaccines, claiming that shared clinical decision-making doesn’t qualify as an official A.C.I.P. recommendation, Mr. Hughes said.
Another rationale is that the R.S.V. vaccine is not yet included on the C.D.C.’s annual vaccine schedule for adults, which 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 R.S.V. “appears on the immunization schedule, it is up to each B.C.B.S. plan to decide if they want to cover.”
Other private insurers are already covering the cost. Teresa Schulteis, 65, of New Berlin, Wis., said she had no trouble getting the vaccine at Walgreens, and it was free using her Medicare Advantage plan through United Healthcare.
Given the varying policies among health insurers, it’s worth calling to check if your plan covers the cost of the vaccine before you make an appointment to get the shot.
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