topline
Some older adults and pregnant women — among the most vulnerable to respiratory syncytial virus (RSV) — are being forced to pay out of pocket (up to $300) this year to purchase the RSV vaccine because of a loophole that excludes it from coverage under all Medicare plans scope.
main facts
Older adults and infants are the most vulnerable to respiratory syncytial virus (RSV) infection, and the U.S. Food and Drug Administration (FDA) has approved two vaccines designed to protect older adults from RSV infection and another vaccine that can be used during pregnancy used by parents for babies.
RSV vaccines (such as shingles and hepatitis A vaccines) are covered by Medicare Part D, which covers vaccines as prescription drugs, but vaccine administration fees may apply.
But about 16 million Medicare beneficiaries are not enrolled in Part D, so they must pay for the RSV vaccine out of pocket, leaving some patients with bills of $330, according to the health policy research group KFF. New York Times Report.
In contrast, several common vaccines, including COVID-19 and flu shots, are covered by Part B, which covers the full cost of the vaccine, including vaccine administration fees.
Even those who sign up for Part D face hurdles: Physician offices are reimbursed for administering vaccines under Part B rather than Part D, so they refer Part D-covered patients to pharmacies to pay for the RSV vaccine out of pocket, but some patients don’t. Give up on vaccines.
Can Medicare beneficiaries increase Part D coverage?
Medicare beneficiaries can add, drop, or switch Part D plans only during open enrollment. The open enrollment period for all beneficiaries is October 15 through December 7, but coverage does not begin until January 1. For beneficiaries of Medicare Advantage plans, the enrollment period is January 1 to March 31 or within the first three months to obtain health insurance. Part D coverage begins on the first day of the following month. There is a different special enrollment period, but it allows people to change plans if they experience a major life change — such as moving to a new address or losing coverage.
big numbers
2.1 million. According to the Centers for Disease Control and Prevention, that’s the number of hospital visits for RSV each year in the United States for children under the age of five. It resulted in more than 160,000 outpatient visits among adults 65 and older. RSV kills 6,000 to 10,000 older adults and 100 to 300 children under five years of age each year.
key quotes
“This is just the result of poor policymaking,” said Richard Hughes IV. Epstein Becker Green, a vaccine law expert and former vice president of public policy at Moderna, told New York Times. “I think vaccines, all vaccines, should be available in all care settings, so this fragmentation is really bad.”
main background
Pfizer and GlaxoSmithKline’s RSV vaccine for people 60 and older was approved by the FDA earlier this year and has been shown to be 94% effective in preventing severe disease. Pfizer’s RSV vaccine, also approved for use in infants in August, is 82% effective in preventing severe disease when given to pregnant parents.
surprising facts
According to the CDC, nearly all children become infected with RSV by their second birthday, but most infections clear up on their own.
further reading
FDA approves Pfizer’s RSV vaccine for seniors – could be available this fall (Forbes)
FDA approves first RSV vaccine after brutal 2022 season (Forbes)
FDA Approves First RSV Vaccine for Children—For Pregnant Moms—Here’s What You Need to Know (Forbes)
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