Frequently Asked Questions
What You Should Know About Coverage Information
The information provided below is not a guarantee of coverage or payment. Providers must follow documentation and billing requirements of payer. Coverage and reimbursement decisions are made by individual plans following receipt of claims from providers. Coverage, reimbursement amount, and administration fee may vary, including by payer, plan, and patient.
Medicare Part D (pharmacy benefit) covers Food and Drug Administration (FDA) approved adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) with a $0 copayment or deductible when administered at an in-network provider.
If the RSV vaccine is not on the formulary yet, a coverage exception request may be made [1].
Generally, the Affordable Care Act (ACA) mandates that non-grandfathered private health plans must provide coverage for vaccines prescribed consistent with Advisory Committee on Immunization Practices (ACIP) recommendations, without cost-sharing when patients access vaccines from an in-network provider.
Under the Inflation Reduction Act (IRA), as of October 1, 2023, state Medicaid agencies (fee for service) must cover FDA approved adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) and the associated vaccine administration without cost sharing. These requirements apply to beneficiaries eligible for full Medicaid benefits whether the benefits are provided through fee-for-service or Medicaid managed care.
State Medicaid agencies and Medicaid managed care entities may vary in their approach to the management of adult vaccines, particularly RSV vaccines. Many but not all states are allowing access to adult vaccines, such as RSV vaccines, under both the Medicaid pharmacy benefit through a pharmacy and the medical benefits when administered in a clinic setting. Check with the state agency or Medicaid managed care organization to determine requirements to ensure appropriate coverage and reimbursement.
Most patients, particularly Medicare beneficiaries, will have access to RSV vaccines through their Medicare Part D benefits if they have them. Health care providers must be in-network and have arrangements in place to bill Medicare Part D pharmacy benefits to ensure coverage and $0 cost share.
Unlike COVID-19 and influenza vaccines, Medicare Part B does not cover RSV vaccines such as mRESVIA®.
If you prefer to print out the information to share with your team, you can access the mRESVIA® coding sheet here.