Respiratory Syncytial Virus (RSV) is a common pathogen that infects the lungs and respiratory tract, typically causing mild, cold-like symptoms. However, the virus can be particularly hazardous for vulnerable populations, including infants and older adults, often leading to severe lower respiratory tract disease and hospitalization. New medical interventions are available to protect these high-risk groups, significantly changing the landscape of prevention. Understanding the cost and insurance coverage for these options requires knowing what kind of protection is offered and who receives it.
The Different Types of RSV Prevention
Protection against severe RSV disease falls into two categories: traditional vaccines and monoclonal antibodies.
Vaccines (Active Immunity)
Vaccines introduce a viral component to the body, prompting the immune system to actively create protective antibodies against the pathogen. This process, known as active immunity, takes a few weeks to generate full protection and offers longer-lasting defense. One vaccine type (e.g., Abrysvo) is administered to pregnant individuals between 32 and 36 weeks of gestation during the RSV season. The mother’s antibodies cross the placenta, providing the newborn with passive immunity for their first several months of life. Other vaccines (e.g., Arexvy, Abrysvo, and mRESVIA) are given directly to adults aged 60 and older to stimulate their immune response.
Monoclonal Antibodies (Passive Immunization)
The second category is a monoclonal antibody, nirsevimab (Beyfortus), administered as an injection to infants. This product is not a vaccine because it does not prompt the baby’s immune system to manufacture antibodies. Instead, it provides immediate, ready-made, lab-created antibodies that directly neutralize the RSV virus upon exposure. This process is called passive immunization. This single shot offers season-long, rapid protection for infants and certain high-risk toddlers.
Cost and Coverage for Adult and Maternal Vaccines
The cost of RSV vaccines for adults and pregnant individuals is largely determined by federal law and insurance type. Because these vaccines are recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP), the Affordable Care Act (ACA) mandates coverage for most patients. Most private health insurance plans must cover the full cost of the shot with no out-of-pocket expenses. This means patients with commercial insurance should not face a copayment or deductible when the vaccine is administered by an in-network provider.
Medicare Coverage
For adults aged 65 and older enrolled in Medicare, coverage is provided under Medicare Part D, the prescription drug plan. Medicare Part D covers the full cost of the vaccine, meaning eligible beneficiaries pay nothing out-of-pocket. Patients who have Original Medicare (Parts A and B) but lack Part D or a Medicare Advantage plan that includes drug coverage may have to pay the full price. Without insurance, the out-of-pocket cost for a single dose of the adult RSV vaccine generally ranges from $250 to $350.
Maternal Vaccine Coverage
Maternal vaccination, which uses the Abrysvo vaccine, follows the same cost-sharing rules as the adult shots. The ACA requires most commercial and Medicaid plans to cover this preventive service for the pregnant individual at no cost. This zero-cost sharing provision extends to both the adult and maternal vaccines, minimizing financial barriers.
Cost and Coverage for Infant Antibody Protection
The cost structure for the infant monoclonal antibody, nirsevimab (Beyfortus), is distinct from vaccines because it is classified as a drug.
Uninsured and Medicaid Coverage
For children who are uninsured, Medicaid-eligible, or American Indian/Alaska Native, the federal Vaccines for Children (VFC) program provides the product free of charge. This program ensures equitable access for children from families with limited financial resources.
Commercial Insurance Coverage
For infants covered by commercial insurance, the ACA mandates that this preventive antibody be covered with no cost-sharing, similar to the adult vaccines. Due to the recent ACIP recommendation, some insurance plans may have administrative delays in updating payment systems. This lag can create temporary hurdles, where a provider may initially bill the family or require a financial waiver. The retail price for the single-dose monoclonal antibody often exceeds $500, making coverage necessary for most families.
Billing Challenges
Supply chain and proper billing procedures have presented challenges affecting out-of-pocket costs. The product is often billed through the medical benefit rather than the pharmacy benefit. Providers must use specific drug-product and administration codes, which can cause confusion and potential claim denials. Despite these complexities, federal programs and commercial mandates aim to ensure infants receive this protection with little to no expense.