{"id":628539,"date":"2024-06-10T13:54:46","date_gmt":"2024-06-10T17:54:46","guid":{"rendered":"https:\/\/www.singlecare.com\/blog\/?p=628539"},"modified":"2024-10-25T09:54:59","modified_gmt":"2024-10-25T13:54:59","slug":"is-arexvy-covered-by-medicare","status":"publish","type":"post","link":"https:\/\/www.singlecare.com\/blog\/is-arexvy-covered-by-medicare\/","title":{"rendered":"Is Arexvy covered by Medicare?"},"content":{"rendered":"<p><span style=\"font-weight: 400;\">Respiratory syncytial virus (RSV) is a common infection of the lungs and breathing passages that causes cold-like symptoms&mdash;but it can also be quite serious.<\/span><a href=\"https:\/\/www.cdc.gov\/rsv\/research\/index.html\" target=\"_blank\" rel=\"noopener\"> <span style=\"font-weight: 400;\">According to the Centers for Disease Control and Prevention<\/span><\/a><span style=\"font-weight: 400;\">, it causes 60,000&ndash;160,000 hospitalizations and 6,000&ndash;10,000 deaths among people ages 65 and older each year. Arexvy, an <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/rsv-vaccine\/\"><span style=\"font-weight: 400;\">RSV vaccine<\/span><\/a><span style=\"font-weight: 400;\">, can reduce the risk of developing RSV-related lower respiratory tract disease by 94.1%, <\/span><a href=\"https:\/\/www.fda.gov\/news-events\/press-announcements\/fda-approves-first-respiratory-syncytial-virus-rsv-vaccine\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">according to the Food and Drug Administration (FDA)<\/span><\/a><span style=\"font-weight: 400;\">.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">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.<\/span><\/p>\n<h2 id=\"does-medicare-cover-arexvy\"><span style=\"font-weight: 400;\">Does Medicare cover Arexvy?&nbsp;<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">In most cases, yes. &ldquo;Not everyone realizes their Part D or Medicare Advantage plan, if it has Part D coverage, has to pay for these vaccines,&rdquo; says <\/span><a href=\"https:\/\/www.medicareresources.org\/authors\/tanya-feke-m-d\/\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">Tanya Feke, MD<\/span><\/a><span style=\"font-weight: 400;\">, a health policy analyst for <\/span><a href=\"http:\/\/medicareresources.org\"><span style=\"font-weight: 400;\">medicareresources.org<\/span><\/a><span style=\"font-weight: 400;\">. The <\/span><a href=\"https:\/\/www.medicare.gov\/coverage\/respiratory-syncytial-virus-rsv-shot\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">Centers for Medicare and Medicaid Services<\/span><\/a><span style=\"font-weight: 400;\"> says that Part D beneficiaries<\/span><span style=\"font-weight: 400;\"> usually pay nothing out of pocket for most vaccines, including the RSV shot. GSK says essentially the same thing&mdash;that <\/span><a href=\"https:\/\/arexvy.com\/get-arexvy\/cost-coverage\/\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">Arexvy is covered for nearly all adults over 60 years of age<\/span><\/a><span style=\"font-weight: 400;\">, and those patients will pay $0 out of pocket thanks to the Inflation Reduction Act.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">This only applies to people with Medicare Part D plans. Medicare Part A doesn&rsquo;t cover drugs, and even though Part B covers some vaccines, Arexvy isn&rsquo;t one of them. Medicare Advantage plans (Part C) often include drug coverage, but you&rsquo;ll want to check with your specific plan.<\/span><\/p>\n<h2 id=\"factors-influencing-medicare-coverage-of-arexvy\"><span style=\"font-weight: 400;\">Factors influencing Medicare coverage of Arexvy&nbsp;<\/span><\/h2>\n<p><a href=\"https:\/\/www.medicare.gov\/coverage\/respiratory-syncytial-virus-rsv-shot\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">Medicare Part D<\/span><\/a><span style=\"font-weight: 400;\"> typically covers all <\/span><a href=\"https:\/\/www.cdc.gov\/vaccines\/hcp\/acip-recs\/index.html\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">vaccines that the Advisory Committee on Immunization Practices (ACIP) recommends<\/span><\/a><span style=\"font-weight: 400;\">. That includes vaccines for RSV, shingles, hepatitis, and others. &ldquo;When the <\/span><a href=\"https:\/\/www.kff.org\/medicare\/issue-brief\/explaining-the-prescription-drug-provisions-in-the-inflation-reduction-act\/\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">Inflation Reduction Act<\/span><\/a> <span style=\"font-weight: 400;\">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,&rdquo; Dr. Feke says.&nbsp;<\/span><\/p>\n<p><span style=\"font-weight: 400;\">But some plans might not include Arexvy on their formularies. Fortunately, it should still be covered. &ldquo;If the vaccine is not on your plan&rsquo;s formulary, you may have to pay upfront for the vaccine and then get your plan to reimburse you after the fact,&rdquo; Dr. Feke says.&nbsp;<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Certain plans might require prior authorization&mdash;additional paperwork from the beneficiary&rsquo;s healthcare provider about the medication&rsquo;s necessity&mdash;but this isn&rsquo;t always the case. &ldquo;Typically, these requirements are in place to ensure that the prescribed medication is used appropriately and as cost-effectively as possible,&rdquo; according to <\/span><a href=\"https:\/\/www.linkedin.com\/in\/les-perlson-34996a61\/\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">Les Perlson<\/span><\/a><span style=\"font-weight: 400;\">, an insurance agent at <\/span><a href=\"https:\/\/www.npabenefits.com\/\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">National Plan Administrators<\/span><\/a><span style=\"font-weight: 400;\">. &ldquo;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&#8217;s coverage criteria.&rdquo;<\/span><\/p>\n<p><span style=\"font-weight: 400;\">The Arexvy website has an<\/span> <a href=\"https:\/\/arexvyhcp.com\/practice-education\/coverage\/\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">insurance checker tool<\/span><\/a><span style=\"font-weight: 400;\"> that can help patients see whether their plans cover the vaccine.<\/span><\/p>\n<h2 id=\"how-much-does-arexvy-cost\"><span style=\"font-weight: 400;\">How much does Arexvy cost?<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">On average, Arexvy costs $630 without any help from insurance, patient assistance programs, or other discounts. Like other prescription drugs, however, that price isn&rsquo;t set in stone. It can vary based on things like inflation, manufacturer policies, and even the pharmacy location. In fact, <\/span><a href=\"https:\/\/www.singlecare.com\/blog\/news\/how-much-do-prescription-prices-vary\/\"><span style=\"font-weight: 400;\">prices can fluctuate greatly between pharmacies<\/span><\/a><span style=\"font-weight: 400;\">, even ones in the same city.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Most people with Medicare coverage won&rsquo;t need to pay a dime for Arexvy, but private insurance plans may have cost-sharing policies&mdash;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&rsquo;ve met your deductible.<\/span><\/p>\n<h2 id=\"alternative-options-if-medicare-doesnt-cover-arexvy\"><span style=\"font-weight: 400;\">Alternative options if Medicare doesn&#8217;t cover Arexvy<\/span><\/h2>\n<p><span style=\"font-weight: 400;\">Not everyone has Medicare. And even some who do&mdash;<\/span><a href=\"https:\/\/www.kff.org\/medicare\/issue-brief\/medicare-part-d-in-2024-a-first-look-at-prescription-drug-plan-availability-premiums-and-cost-sharing\/\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">roughly 16 million<\/span><\/a><span style=\"font-weight: 400;\">&mdash;don&rsquo;t have Part D drug plans. Plus, some private insurance plans won&rsquo;t cover the RSV vaccines. Fortunately, paying full price out of pocket isn&rsquo;t the only other option. There are a few other reliable ways to save money on Arexvy.&nbsp;<\/span><\/p>\n<h3 id=\"sign-up-for-arexvy-coupons\"><span style=\"font-weight: 400;\">Sign up for Arexvy coupons<\/span><\/h3>\n<p><span style=\"font-weight: 400;\">A free <\/span><a href=\"https:\/\/www.singlecare.com\/prescription-discount-card\"><span style=\"font-weight: 400;\">SingleCare prescription discount card<\/span><\/a><span style=\"font-weight: 400;\"> 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, <\/span><a href=\"https:\/\/www.singlecare.com\/prescription\/arexvy\"><span style=\"font-weight: 400;\">you could pay around $284<\/span><\/a><span style=\"font-weight: 400;\">, 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&rsquo;t stack coupons on top of your coverage.<\/span><\/p>\n<h3 id=\"apply-for-medicaid\"><span style=\"font-weight: 400;\">Apply for Medicaid<\/span><\/h3>\n<p><span style=\"font-weight: 400;\">Anyone who has Medicare and meets certain financial requirements may also be eligible for Medicaid&mdash;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 <\/span><i><span style=\"font-weight: 400;\">without <\/span><\/i><span style=\"font-weight: 400;\">Part D, and then qualify for Medicaid, you will be automatically facilitated into a standalone Part D plan. The<\/span> <a href=\"https:\/\/www.medicaid.gov\/medicaid\/eligibility\/index.html\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">Medicaid <\/span><span style=\"font-weight: 400;\">eligibility requirements<\/span><\/a><span style=\"font-weight: 400;\"> vary by state, so<\/span> <a href=\"https:\/\/www.medicaid.gov\/state-overviews\/state-profiles\/index.html\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">check with your state<\/span><\/a><span style=\"font-weight: 400;\"> to apply.<\/span><\/p>\n<h3 id=\"look-into-other-government-and-nonprofit-assistance\"><span style=\"font-weight: 400;\">Look into other government and nonprofit assistance<\/span><\/h3>\n<p><span style=\"font-weight: 400;\">Nonprofit organizations like the<\/span> <a href=\"https:\/\/copays.org\/\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">Patient Advocate Foundation<\/span><\/a><span style=\"font-weight: 400;\"> and the<\/span> <a href=\"https:\/\/www.panfoundation.org\/\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">PAN Foundation<\/span><\/a><span style=\"font-weight: 400;\"> offer aid and grants to help patients pay for their prescription drugs. But, like Medicaid, you&rsquo;ll need to meet certain requirements to qualify.<\/span> <a href=\"https:\/\/www.ncsl.org\/health\/state-pharmaceutical-assistance-programs\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">Each state also has patient assistance programs<\/span><\/a><span style=\"font-weight: 400;\">, <\/span><span style=\"font-weight: 400;\">which may contribute to out-of-pocket drug costs.<\/span><\/p>\n<h3 id=\"consider-an-hsa-or-fsa\"><span style=\"font-weight: 400;\">Consider an HSA or FSA<\/span><\/h3>\n<p><span style=\"font-weight: 400;\">Health savings accounts (HSAs) and flexible spending accounts (FSAs) &ldquo;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,&rdquo; Perlson says. &ldquo;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.&rdquo;&nbsp;<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Since Medicare covers Arexvy, this would primarily apply to private insurance plans or cases when patients have to pay for Arexvy upfront.&nbsp;<\/span><\/p>\n<h3 id=\"ask-about-alternatives\"><span style=\"font-weight: 400;\">Ask about alternatives<\/span><\/h3>\n<p><span style=\"font-weight: 400;\">Currently, the only <\/span><a href=\"https:\/\/www.fda.gov\/vaccines-blood-biologics\/abrysvo\" target=\"_blank\" rel=\"noopener\"><span style=\"font-weight: 400;\">FDA-approved alternative to Arexvy<\/span><\/a><span style=\"font-weight: 400;\"> is Pfizer&rsquo;s Abrysvo. While Arexvy may be cheaper than <\/span><a href=\"https:\/\/www.singlecare.com\/prescription\/abrysvo\"><span style=\"font-weight: 400;\">Abrysvo<\/span><\/a><span style=\"font-weight: 400;\"> in many cases, it can&rsquo;t hurt to compare prices. Consult a healthcare provider about which vaccine would be better for you.<\/span><\/p>\n<h3 id=\"locate-less-expensive-pharmacy-options\"><span style=\"font-weight: 400;\">Locate less expensive pharmacy options<\/span><\/h3>\n<p><span style=\"font-weight: 400;\">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.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Respiratory syncytial virus (RSV) is a common infection of the lungs and breathing passages that causes cold-like symptoms&mdash;but it can also be quite serious. According to the Centers for Disease Control and Prevention, it causes 60,000&ndash;160,000 hospitalizations and 6,000&ndash;10,000 deaths among people ages 65 and older each year. Arexvy, an RSV vaccine, can reduce the [&hellip;]<\/p>\n","protected":false},"author":15,"featured_media":628540,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[4589],"tags":[15,3381],"coauthors":[8861],"class_list":["post-628539","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-drug-info","tag-medicare","tag-vaccines","wpautop"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.4 (Yoast SEO v27.4) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Is Arexvy covered by Medicare?<\/title>\n<meta name=\"description\" content=\"Medicare Part D plans typically cover the entire cost of Arexvy for RSV, although the drug might not be listed on all formularies.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" 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