Medicare coverage for Abrysvo depends on your age and whether you meet specific criteria

Abrysvo is a vaccine that protects against respiratory syncytial virus (RSV), a respiratory infection that can be serious in older adults. Medicare Part B covers Abrysvo for adults aged 60 and older, with no copay or coinsurance when you receive it at an in-network provider. The vaccine is administered as a single injection, usually in the arm.

Coverage became available after the FDA approved Abrysvo for older adults. Your doctor can discuss whether this vaccine is right for you based on your health history and risk factors. If you are under 60, coverage through Medicare Part B is not available, though you may have other coverage options through a Medicare Advantage plan or private insurance.

Key Takeaways

  • Medicare Part B covers Abrysvo at no cost for adults aged 60 and older when given at an in-network provider.
  • You do not need a prescription; your doctor can administer the vaccine during an office visit.
  • If you have a Medicare Advantage plan, coverage may differ, so check your plan documents or call your plan directly.
  • The vaccine is a single dose and protects against RSV, which can cause serious respiratory illness in older adults.

How to receive Abrysvo under Medicare Part B

Start by scheduling an appointment with your primary care doctor or a healthcare provider who accepts Medicare. Tell them you are interested in the RSV vaccine. Your provider will review your medical history and discuss whether Abrysvo is appropriate for you. If your doctor recommends it, they can administer the vaccine at that visit.

Make sure your provider is in-network with Medicare to avoid unexpected costs. You can verify this by calling your provider's office or checking the Medicare provider search tool on Medicare.gov. When you arrive for your appointment, bring your Medicare card. There is no copay, coinsurance, or deductible for the vaccine itself when given at an in-network location.

What happens if you have a Medicare Advantage plan

Medicare Advantage plans (Part C) must cover all vaccines that Original Medicare covers, including Abrysvo. However, your out-of-pocket cost may vary depending on your specific plan. Some plans cover the vaccine with no cost; others may charge a copay or coinsurance.

Contact your Medicare Advantage plan directly to learn your coverage details before scheduling the vaccine. You can find the phone number on your plan's member card or on the plan's website. Ask specifically whether Abrysvo is covered and what your cost will be. Your plan can also tell you which providers in your area are in-network for vaccine administration.

Medicare Advantage plans and vaccine coverage

If you are enrolled in a Medicare Advantage plan, the plan must cover Abrysvo because it is a vaccine covered by Original Medicare. However, the plan sets its own cost-sharing rules. Some plans cover all preventive vaccines with no copay; others charge a copay per visit or per vaccine.

The best way to know your exact cost is to call your plan's customer service number before your appointment. Have your member ID ready. Ask whether you need prior authorization from your plan before receiving the vaccine. Some plans require this step, and skipping it could result in a higher bill.

What to do if your provider is out-of-network

If your doctor does not accept Medicare or is out-of-network, you may still receive Abrysvo, but you could face higher costs. Under Original Medicare, you are responsible for any charges above what Medicare allows. This means the provider can bill you for the difference between their fee and Medicare's approved amount.

To avoid this, ask your current provider whether they accept Medicare before scheduling. If they do not, ask for a referral to an in-network provider who offers the RSV vaccine. You can also search for in-network providers using the Medicare provider search tool or by calling 1-800-MEDICARE.

Timing and side effects to expect

Abrysvo is given as a single injection, so you do not need multiple visits or follow-up doses. The vaccine can be given at any time of year, though some people prefer to receive it in the fall before RSV season peaks. Your doctor can help you decide the best timing based on your schedule and health.

Common side effects are mild and temporary, including soreness or redness at the injection site, fatigue, or muscle aches. These usually resolve within a few days. Serious side effects are rare. If you have concerns about side effects or have had reactions to vaccines in the past, discuss this with your doctor before the appointment.

Frequently Asked Questions

Do I need a referral to get Abrysvo?

No, you do not need a referral. You can call your primary care doctor or any healthcare provider who administers vaccines and ask to schedule an appointment for the RSV vaccine. If your doctor recommends it, they can give it to you at that visit.

What if I am under 60 but have a serious health condition?

Medicare Part B covers Abrysvo only for adults aged 60 and older. If you are younger, check with your Medicare Advantage plan or private insurance to see whether they cover the vaccine. Your doctor can also discuss your individual risk and whether the vaccine may be right for you outside of Medicare coverage.

Can I get Abrysvo at a pharmacy instead of my doctor's office?

Yes, some pharmacies that accept Medicare administer Abrysvo. Call ahead to confirm the pharmacy has the vaccine in stock and that it is in-network with your Medicare plan. Bring your Medicare card when you go.

Will I need to pay anything out of pocket?

Under Original Medicare, there is no copay, coinsurance, or deductible for Abrysvo when given at an in-network provider. If you have a Medicare Advantage plan, your cost depends on your plan's rules. Contact your plan to confirm before your appointment.

What if my doctor says I should not get the vaccine?

Some people may not be good candidates for Abrysvo due to allergies or certain medical conditions. If your doctor recommends against it, that is the right decision for you. You do not need to pursue the vaccine if your healthcare provider advises against it.