RSV is a common, highly contagious respiratory pathogen that can cause severe illness, particularly in adults aged 60 and older. An RSV infection can progress into serious conditions such as pneumonia or bronchiolitis, often requiring hospitalization. Navigating the costs associated with both preventing and treating this illness requires understanding the different components of Medicare: Parts A, B, C, and D. This system determines how much a beneficiary will pay for preventive vaccines versus the potential expenses of hospital and medical care if the virus is contracted.
Prevention Coverage for the RSV Vaccine
The introduction of new vaccines targeting RSV has provided older adults with a direct tool for prevention. Unlike the flu shot, which is covered under Medicare Part B, the RSV vaccine is covered under Medicare Part D, the prescription drug benefit. This is a result of the Inflation Reduction Act of 2022, which expanded Part D coverage to include all vaccines recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP).
For eligible beneficiaries aged 60 and over, the vaccine is provided at no cost, meaning there is no copayment, coinsurance, or deductible applied. This zero-cost-sharing rule applies regardless of whether the vaccine is administered at a physician’s office or a participating pharmacy that bills the Part D plan.
Beneficiaries should confirm that the provider or pharmacy is in their Part D plan’s network to ensure the cost-free benefit is processed correctly. If a person has Original Medicare (Parts A and B) but has not enrolled in a separate Part D plan, they would be responsible for the full retail price of the vaccine. Medicare Advantage plans that include prescription drug coverage (MAPD) also cover the RSV vaccine at no cost as part of their integrated Part D benefit. The three FDA-approved vaccines, including Arexvy, Abrysvo, and mResvia, are covered under this provision.
Treatment Coverage for Inpatient and Outpatient Care
If an older adult contracts RSV and requires medical attention, coverage shifts from the preventive Part D benefit to Original Medicare, specifically Parts A and B. Medicare Part A covers hospital insurance and pays for inpatient care, such as hospitalization needed for severe RSV complications like low blood oxygen levels or acute respiratory failure. The financial structure of Part A is based on a benefit period, which begins on the day of hospital admission and ends after the beneficiary has been out of the hospital for 60 consecutive days.
In 2025, the Part A deductible is $1,676 per benefit period, which the beneficiary must pay before Medicare begins to cover the costs. For an inpatient stay up to 60 days within a single benefit period, the patient pays only this deductible. If the RSV-related hospitalization extends beyond 60 days, a daily coinsurance is introduced, amounting to $419 per day for days 61 through 90 in 2025.
Medicare Part B covers medical insurance, which applies to outpatient services related to an RSV infection. This includes necessary doctor visits, emergency room services if the patient is not formally admitted as an inpatient, and diagnostic testing for the virus. Part B also covers durable medical equipment, such as a nebulizer, if deemed medically necessary for managing respiratory symptoms.
The cost-sharing for Part B services is based on an annual deductible, which is $257 in 2025. After this annual deductible is met, the patient is responsible for a 20% coinsurance of the Medicare-approved amount for all Part B-covered services.
Understanding Prescription Drug and Out-of-Pocket Costs
The Part D plan that covers the RSV vaccine also covers prescription medications used to treat the infection, such as inhalers, certain antivirals, or antibiotics for secondary bacterial infections. The structure of Part D for treatment drugs has been significantly redesigned for 2025 due to the Inflation Reduction Act, which removes the previous coverage gap, often called the “donut hole.”
The first phase is the deductible period, with a maximum deductible of $590 in 2025, which the beneficiary generally pays in full before coverage begins. Once the deductible is met, the plan enters the initial coverage phase, where the beneficiary is responsible for 25% of the drug cost, typically through a copayment or coinsurance.
The most significant change is the introduction of a $2,000 annual cap on out-of-pocket spending for covered Part D drugs. Once a beneficiary’s spending reaches this threshold, they immediately enter the catastrophic coverage phase. In this final phase, the enrollee pays $0 for covered prescription drugs for the remainder of the calendar year. The total out-of-pocket exposure for an RSV event combines the Part A deductible, the Part B deductible and 20% coinsurance, and the Part D cost-sharing up to the $2,000 cap.
How Medicare Advantage and Medigap Affect Coverage
The costs and coverage rules of Original Medicare (Parts A and B) can be modified substantially when a beneficiary chooses a private alternative, such as a Medicare Advantage plan (Part C) or a Medigap policy. Medicare Advantage plans are required to cover all the same services as Original Medicare, including both RSV treatment and the zero-cost vaccine. These plans replace the Part A and B deductibles and coinsurance with their own cost-sharing rules, often using copayments for services like hospital stays and doctor visits.
A primary feature of Medicare Advantage plans is the Maximum Out-of-Pocket (MOOP) limit, which Original Medicare does not have. For 2025, this MOOP can be up to $9,350 for in-network services, providing a financial safety net for a severe, high-cost illness. Most Medicare Advantage plans also integrate Part D coverage, simplifying the prescription drug benefit and incorporating the $2,000 drug spending cap.
For those who remain on Original Medicare, a Medigap policy provides supplemental coverage to fill the financial gaps left by Parts A and B. Depending on the specific plan chosen, Medigap can pay the Part A hospital deductible and the Part B 20% coinsurance, effectively leaving the beneficiary with minimal or zero out-of-pocket costs for covered treatment. A Medigap policy does not include prescription drug coverage, so beneficiaries must purchase a separate Part D plan to ensure they receive the zero-cost RSV vaccine and coverage for any treatment medications.