Updated Dec. 7 – this article was edited to clarify details of RSV vaccine coverage.
OHA is aware of some people being unexpectedly charged for COVID-19 and respiratory syncytial virus (RSV) vaccines. There are a few reasons why this might happen, and we always recommend checking with your insurer if you have questions. We understand the insurance landscape for vaccines can be confusing and frustrating, especially as we move out of the pandemic.
During the public health emergency, the federal government purchased COVID-19 vaccines directly from manufacturers and distributed them at no cost to states and the public. Now that the public health emergency is over, COVID-19 vaccines have moved into the commercial market, and manufacturers are selling them directly to providers and pharmacies, as they do for other vaccines. The providers and pharmacies must then bill insurance companies to get reimbursed after they administer a vaccine to a patient. If they can’t bill insurance, they will charge the patient.
The new RSV vaccine for older adults only recently entered the commercial market, and some insurance companies have not yet updated their policies to include it on their lists of covered vaccines. This has led to reports of some people being charged upwards of $300 for it. We’ve heard similar reports about COVID-19 vaccines, as well as pharmacies filing Medicare claims incorrectly, resulting in a rejection of coverage.
Here is a rundown of some basic facts about coverage for COVID-19, RSV and flu vaccines. This list is accurate as of the publication date of this article, and some details may change over time as the insurance landscape continues to evolve.
2023-2024 COVID-19 vaccine for adults age 18+
- Fully covered by all Marketplace plans and most other private insurance plans at no cost to the patient anywhere the vaccine is offered. It’s best to go to an in-network provider or pharmacy, but if you can’t find one, call your insurer in advance to arrange full coverage of the vaccine at an out-of-network location.
- Fully covered by Medicare Part B at no cost to the patient anywhere the vaccine is offered. If using a pharmacy, confirm the pharmacy will bill Medicare Part B.
- Fully covered by Medicare Advantage plans at no cost to the patient at in-network providers and pharmacies.
- Fully covered by Oregon Health Plan (OHP/Medicaid) at no cost to the patient anywhere the vaccine is offered that also accepts OHP, which includes most retail pharmacies.
- Fully covered for uninsured and underinsured adults through pharmacies participating in the CDC’s Bridge Access Program. (“Underinsured” means a person’s insurance policy covers some but not all COVID-19 vaccine costs.) Note: In Oregon, if you go to a participating local public health authority (LPHA) or federally qualified health center (FQHC), the Bridge Access Program will fully cover the COVID-19 vaccine for uninsured people, but it will not cover the shot for underinsured people. Find participating vaccine providers by using the Vaccines.gov search tool and filtering by “Bridge Access Program Participant.”
RSV vaccine for people age 60+
- Fully covered by Medicare Part D with no cost to the patient at pharmacies that contract with the patient’s Medicare Part D plan. Doctors’ offices do not contract with Medicare Part D, so Medicare Part D members must go to an in-network pharmacy to receive this vaccine at no cost.
- Fully covered by Medicare Advantage plans with Part D at no cost to the patient at in-network providers and pharmacies. Without a Part D component, Medicare Advantage plans do not cover the RSV vaccine.
- For adults 60+ without Medicare, the shot is fully covered by many private insurance plans at no cost to the patient at in-network providers and pharmacies. Call your insurer in advance to confirm coverage and learn about in-network locations. Also, if you go to a pharmacy, call in advance to confirm they have the RSV vaccine in stock and that you are eligible to receive it without a prescription from your health care provider.
- Fully covered by Oregon Health Plan (OHP/Medicaid) at no cost anywhere the vaccine is offered that also accepts OHP, which includes most retail pharmacies.
- If you are uninsured or underinsured (ie: Medicare without Part D), there are a couple options. You could look for a Federally Qualified Health Center (FQHC) near you and become a patient there. They offer sliding scale discounts for services and medications based on income. People can search for Oregon FQHCs near them using the Oregon Primary Care Association website, this OHA document, or nationwide with this federal locator tool. Additionally, the two FDA-approved RSV vaccines are made by Pfizer and GlaxoSmithKline, and Pfizer offers a patient assistance program for eligible uninsured people to receive the “Abrysvo” RSV vaccine at low- or no-cost. However, if you are underinsured, you may qualify for Pfizer’s reimbursement assistance, and we recommend calling Pfizer Vaccines Reimbursement Support Services (844-989-7284) for details on your eligibility and the process.
Flu vaccine
- Fully covered by all Marketplace plans and most other private insurance plans at no cost to the patient at in-network providers and pharmacies. Call your insurer in advance to confirm.
- Fully covered by Medicare Part B, with no cost to the patient anywhere the vaccine is offered.
- Those with Medicare Advantage plans must go to providers or pharmacies that are in-network to receive the flu vaccine at no cost.
- Fully covered by Oregon Health Plan (OHP/Medicaid) at no cost anywhere the vaccine is offered that also accepts OHP, which includes most retail pharmacies.
Children — COVID-19 and flu vaccines
- 2023-2024 COVID-19 vaccines are fully covered by all Marketplace plans and most other private insurance plans at no cost to the patient anywhere the vaccine is offered. It’s best to go to an in-network provider or pharmacy*, but if you can’t find one, call your insurer in advance to arrange full coverage at an out-of-network location.
- Flu vaccines are fully covered by all Marketplace plans and most other private insurance plans at in-network providers and pharmacies*. Call your insurer in advance to confirm.
- Children age 18 and under who are enrolled in OHP/Medicaid, or those who are uninsured, underinsured or American Indian/Alaska Native, can receive the 2023-2024 COVID-19 and flu vaccines at no cost from providers that participate in the federal Vaccines for Children (VFC) program. VFC providers can include private doctors and clinics, schools, hospitals, public health clinics, retail pharmacies, community health clinics and Tribal health departments. Search for VFC providers or pharmacies here.
- Eligible children (and adults) in Oregon can also receive vaccines at no cost through OHA’s Vaccine Access Program (VAP). Search for VAP providers or pharmacies here.
- Fully covered at no cost to those 18 and under who are enrolled in OHP/Medicaid anywhere flu and COVID-19 vaccines are offered that also accepts OHP, which includes most retail pharmacies.
* Oregon pharmacies can administer COVID-19 and flu vaccines (not other routine childhood vaccines) to children as young as 3 through Dec. 2024. After that, the minimum age for children to receive any vaccines at a pharmacy returns to 7 years old.
If you feel you were wrongly charged for a vaccine, the first step is to try to get a refund from the provider or pharmacy. If you are unsuccessful, the next step is to file a complaint with the U.S. Department of Health and Human Services Office of the Inspector General hotline by calling 800-447-8477 or using this online form.
If you’re enrolled in Medicare (with or without a supplemental plan), and a provider or pharmacy tells you the vaccine you’re getting is not covered and you believe that is incorrect, call 1-800-MEDICARE (1-800-633-4227) for help. If you have a Medicare Advantage plan, call your insurer for help, not Medicare.
Read more about the 2023-2024 mRNA COVID-19 vaccines here, and search for COVID-19 and flu vaccines at Vaccines.gov.