Shots for Fall

Respiratory illnesses coming our way

Covid cases are rising. Flu season is around the corner. New vaccines for the virus known as RSV recently became available.

Who should get the various vaccines and when?

“For the eligible populations, all three shots are highly recommended,” said Georges Benjamin, a physician and the executive director of the American Public Health Association.

Older people start to lose immunity as they age. They’re unable to fight off infections, such as RSV, as well as they did when they were younger.

♦ Still, there’s no need to get them all at the same time, and there are reasons to wait a bit for two of them (Flu & COVID-19). Some people may also face cost issues.

COVID-19 shots will have new updated versions available in the fall. Most people will still be able to get the vaccines for free.

♦ The federal government stopped picking up the entire tab for COVID-19 shots when the public health emergency ended this spring. Now the actual cost of the vaccine will be borne by private insurers, Medicare and Medicaid.

• The new COVID flavors are expected to be approved by the end of September.

The Food and Drug Administration approved two RSV vaccines earlier this year for adults aged 60 and up.

If you are not an infant or over the age of 60 and are otherwise healthy, you probably don’t need a preventive therapy, Dr. Thomas Murray of Yale Medicine explains. “Virtually every child has experienced RSV by the age of 2 and has immunity. Older children, teenagers, and most adults have strong immunity from multiple exposures,” he says.

• Always discuss your situation with your family doctor before making any decision.

Not covered

Beware, some insurance plans aren’t covering the RSV cost, forcing people to pay hundreds of dollars if they want to be protected.

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 RSV.

• The RSV vaccines, as well as the vaccine for shingles, are covered under Medicare Part D.

Medicare enrollees without a Part D plan — roughly 16 million people — may have to pay for the RSV vaccine out of pocket depending on their non-Medicare prescription drug coverage.

♦ The RSV 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.

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. This is a key point for getting reimbursed. Having your doctor prescribe the shot. Just deciding on your own usually won’t fly.

• 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.

• 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 ACIP recommendations for the RSV vaccine put the final decision in the hands of individuals in consultation with their doctors.

The ACIP guidance says that anyone aged 60 years or older may receive a single dose of RSV 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 ACIP recommendation.

Some private health insurers are also refusing to cover RSV vaccines under the rationale that the vaccine is not yet included on the CDC’s annual vaccine schedule for adults.

• This vaccine schedule will most likely not be updated until early 2024.

♦ While private insurers are not required to cover the RSV vaccine until it appears on the immunization schedule, many plans have decided to cover it at this time.

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.

What is RSV?

RSV stands for Respiratory Syncytial (sin-SISH-uhl) Virus. It is a respiratory virus that infects the lungs and breathing passages.

• RSV can cause more severe infections such as bronchiolitis and pneumonia. It is the most common cause of bronchiolitis and pneumonia in children younger than 1 year of age.

Healthy adults and infants infected with RSV do not usually need to be hospitalized. But some people with RSV infection, especially older adults and infants younger than 6 months of age, may need to be hospitalized if they are having trouble breathing or are dehydrated.

In the most severe cases, a person may require additional oxygen, or IV fluids or intubation (a breathing tube) with ventilation. In most of these cases, hospitalization only lasts a few days.

• 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.

Cost without insurance

The new RSV vaccines are expected to range between $180 and $300 a shot.

Pfizer and Moderna, two of the companies producing updated COVID-19 vaccines, previously suggested they would charge $110 to $130 per dose. They also said they plan to offer programs for people who cannot afford the vaccines.

The cost of the flu vaccine depends on the type of shot and the pharmacy or medical outlet providing it but can range from $20 to more than $70.