Is Arexvy covered by Medicare?

In this article:

• Does Medicare cover Arexvy? 
• Factors influencing Medicare coverage of Arexvy 
• How much does Arexvy cost?
• Alternative options if Medicare doesn't cover Arexvy

In this article

• Does Medicare cover Arexvy? 
• Factors influencing Medicare coverage of Arexvy 
• How much does Arexvy cost?
• Alternative options if Medicare doesn't cover Arexvy

Respiratory syncytial virus (RSV) is a common infection of the lungs and breathing passages that causes cold-like symptoms—but it can also be quite serious. According to the Centers for Disease Control and Prevention, it causes 60,000–160,000 hospitalizations and 6,000–10,000 deaths among people ages 65 and older each year. Arexvy, an RSV vaccine, can reduce the risk of developing RSV-related lower respiratory tract disease by 94.1%, according to the Food and Drug Administration (FDA).

Manufactured by GSK, average retail price of Arexvy is $630.16 for a dose of the vaccine. But the price varies and ultimately depends on factors such as your insurance drug coverage and where you go to get your vaccine. Medicare Part D often covers Arexvy for older adults, but it varies between plans and patients.

Does Medicare cover Arexvy? 

In most cases, yes. “Not everyone realizes their Part D or Medicare Advantage plan, if it has Part D coverage, has to pay for these vaccines,” says Tanya Feke, MD, a health policy analyst for medicareresources.org. The Centers for Medicare and Medicaid Services says that Part D beneficiaries usually pay nothing out of pocket for most vaccines, including the RSV shot. GSK says essentially the same thing—that Arexvy is covered for nearly all adults over 60 years of age, and those patients will pay $0 out of pocket thanks to the Inflation Reduction Act.

This only applies to people with Medicare Part D plans. Medicare Part A doesn’t cover drugs, and even though Part B covers some vaccines, Arexvy isn’t one of them. Medicare Advantage plans (Part C) often include drug coverage, but you’ll want to check with your specific plan.

Factors influencing Medicare coverage of Arexvy 

Medicare Part D typically covers all vaccines that the Advisory Committee on Immunization Practices (ACIP) recommends. That includes vaccines for RSV, shingles, hepatitis, and others. “When the Inflation Reduction Act passed in 2022, it made vaccines covered by Part D free to Medicare beneficiaries just like vaccines that are covered by Medicare Part B. That means you do not have to pay toward your deductible, the cost of the vaccine, or for any dispensing or administrative fees,” Dr. Feke says. 

But some plans might not include Arexvy on their formularies. Fortunately, it should still be covered. “If the vaccine is not on your plan’s formulary, you may have to pay upfront for the vaccine and then get your plan to reimburse you after the fact,” Dr. Feke says. 

Certain plans might require prior authorization—additional paperwork from the beneficiary’s healthcare provider about the medication’s necessity—but this isn’t always the case. “Typically, these requirements are in place to ensure that the prescribed medication is used appropriately and as cost-effectively as possible,” according to Les Perlson, an insurance agent at National Plan Administrators. “For Arexvy, if prior authorization is needed, it would likely involve confirming the medical necessity of the vaccine for the patient and ensuring that it aligns with the plan’s coverage criteria.”

The Arexvy website has an insurance checker tool that can help patients see whether their plans cover the vaccine.

How much does Arexvy cost?

On average, Arexvy costs $630 without any help from insurance, patient assistance programs, or other discounts. Like other prescription drugs, however, that price isn’t set in stone. It can vary based on things like inflation, manufacturer policies, and even the pharmacy location. In fact, prices can fluctuate greatly between pharmacies, even ones in the same city.

Most people with Medicare coverage won’t need to pay a dime for Arexvy, but private insurance plans may have cost-sharing policies—even when they cover it. These policies may require the beneficiary to cover copays, co-insurance, or other out-of-pocket costs, even after you’ve met your deductible.

Alternative options if Medicare doesn’t cover Arexvy

Not everyone has Medicare. And even some who do—roughly 16 million—don’t have Part D drug plans. Plus, some private insurance plans won’t cover the RSV vaccines. Fortunately, paying full price out of pocket isn’t the only other option. There are a few other reliable ways to save money on Arexvy. 

Sign up for Arexvy coupons

A free SingleCare prescription discount card gives you discounts on thousands of medications, including Arexvy. SingleCare works directly with pharmacies to help patients take hundreds off their out-of-pocket costs. So, instead of paying the average price of $630 for your vaccine, you could pay around $284, depending on the pharmacy. Anyone can sign up for a SingleCare prescription discount card, even if you already have Medicare or private insurance. However, you can’t stack coupons on top of your coverage.

Apply for Medicaid

Anyone who has Medicare and meets certain financial requirements may also be eligible for Medicaid—a government-funded assistance program for medical expenses. People with Medicare Part D already receive full drug coverage, but people with only Part A or Part B may benefit from Medicaid coverage. In most cases, if you have Medicare without Part D, and then qualify for Medicaid, you will be automatically facilitated into a standalone Part D plan. The Medicaid eligibility requirements vary by state, so check with your state to apply.

Look into other government and nonprofit assistance

Nonprofit organizations like the Patient Advocate Foundation and the PAN Foundation offer aid and grants to help patients pay for their prescription drugs. But, like Medicaid, you’ll need to meet certain requirements to qualify. Each state also has patient assistance programs, which may contribute to out-of-pocket drug costs.

Consider an HSA or FSA

Health savings accounts (HSAs) and flexible spending accounts (FSAs) “allow individuals to use pretax dollars to cover out-of-pocket expenses, which can include vaccines not fully covered by Medicare or other insurance plans,” Perlson says. “In situations where the Arexvy vaccine might not be fully covered, directing patients toward utilizing these accounts for payment can ease the financial burden significantly.” 

Since Medicare covers Arexvy, this would primarily apply to private insurance plans or cases when patients have to pay for Arexvy upfront. 

Ask about alternatives

Currently, the only FDA-approved alternative to Arexvy is Pfizer’s Abrysvo. While Arexvy may be cheaper than Abrysvo in many cases, it can’t hurt to compare prices. Consult a healthcare provider about which vaccine would be better for you.

Locate less expensive pharmacy options

Since each pharmacy sets its own prices, you might find lower prices by simply calling around. Driving across town to a different pharmacy might be less convenient, but it could also save hundreds in certain situations.