If you’re planning to get a Covid vaccine this fall, there may be some surprises regarding coverage. The FDA is likely to approve new Covid shots soon, but only for certain groups: adults 65 and older and those with specific health conditions. This means the CDC might limit recommendations for who should get the vaccine to these high-risk groups, even though they currently suggest vaccination for everyone aged six months and older.
Because of this shift, insurance coverage for Covid shots could change. Normally, insurance plans must cover vaccines recommended by the CDC. However, with the new recommendations, coverage for those outside the high-risk category will depend on individual insurance policies. Some plans might cover the vaccine fully, while others may require a copay or not cover it at all. If you’re paying out of pocket, a Covid shot can cost around $140.
Dr. William Schaffner, an infectious disease expert, emphasizes that whether someone can get a free vaccine will largely depend on their insurance provider.
Who Can Get a Covid Vaccine?
Under the CDC’s upcoming guidelines, healthy children and adults won’t be completely excluded from getting the Covid vaccine. Dorit Reiss, a vaccine policy expert, points out that doctors can prescribe vaccines “off-label,” and insurance companies may choose to cover these shots.
Insurers will decide their own policies after the CDC releases its final guidance. The CDC lists various health conditions that increase the risk of severe Covid illness—these include cancer, heart disease, and even mental health issues. Recommendations from organizations like the American Academy of Pediatrics may also influence what insurers decide.
Changes to insurance coverage might not happen immediately. The spokesperson for AHIP (the health insurance industry trade group) notes that for most private plans, any updates would likely take effect at the beginning of the next benefit year. This could mean that people getting vaccinated before January 1 might be covered. However, Medicare and Medicaid must follow CDC recommendations as soon as the director signs off.
Some insurers, like Blue Cross and Blue Shield, will make their own decisions about coverage. Aetna has indicated that pregnant women and children can receive the new Covid booster without any copay. The rules for healthy adults, though, might differ.
Combining Covid and Flu Shots
The upcoming changes could also impact those looking to get vaccinated against both Covid and the flu at the same time. Experts, like Dr. Schaffner, express concern that individuals may be turned away because of the new recommendations. Misinformation could further discourage many from getting vaccinated.
Rick Gates, Walgreens’ chief pharmacy officer, reassures patients that pharmacists will check insurance coverage before administering vaccines. This means that surprises about bills are less likely. Gates notes that patient interest in the Covid vaccine may be lower right now, especially as they wait for the updated version. Interestingly, during last year’s flu season, over 50% of patients got both vaccines simultaneously, a trend that has been increasing in recent years.
Staying informed about vaccine availability and coverage options will help ensure that you can protect yourself and your family effectively this fall. For more information on vaccine pricing and recommendations, visit the CDC’s vaccine price list.
