Why Medicare May Not Yet Cover the Latest COVID Vaccine: What You Need to Know

Older Americans on Medicare are facing a surprising challenge: the new COVID-19 vaccines, recently approved for those 65 and older, are not being covered by Medicare. This leaves many to consider paying out of pocket for their shots.

Take Allison Engel, a 74-year-old from Pasadena, California. When she visited her local CVS, she learned the shot would cost her $225. Frustrated, she received a rejection letter stating that the vaccine wasn’t yet in the Medicare system. “I didn’t want to wait,” she said, so she opted to pay out of pocket, hoping to get reimbursed later.

Brant Mittler, 78, experienced a similar issue in San Antonio. He and his wife encountered the same frustration. “We’ve had Medicare patients coming in all day, and everyone’s upset because we can’t give it,” the pharmacist told them. Luckily, they were able to get their shots a few days later after the system had been updated.

These experiences clash with statements from Health Secretary Robert F. Kennedy Jr. He told a Senate committee that most Americans should be able to receive the COVID shot without cost. However, the reality on the ground tells a different story. While the FDA approved updated vaccines for those aged 65 and older and at-risk individuals, accessibility is still a major concern.

Experts like Arthur Caplan, head of medical ethics at NYU, highlight the confusion surrounding the eligibility for these vaccines. “This just stirs up uncertainty about, ‘Am I eligible? Am I in the risk group?’” he explained. “Medicare should be covering the shots, but if it isn’t, that’s problematic.”

As these new vaccines begin rolling out at major pharmacies, there are reports that some pharmacies are holding off until the CDC’s Advisory Committee on Immunization Practices (ACIP) issues its recommendations. Typically, the committee meets earlier in the summer, but this year, it’s scheduled for September 18.

Dorit Reiss, a vaccine policy expert at the University of California, San Francisco, pointed out that Medicare doesn’t have to wait for the CDC’s approval. “Once the FDA approves a vaccine, Medicare can cover it,” she said.

CVS, one of the largest pharmacy chains, has specific policies depending on the state. In 13 states and Washington, D.C., Medicare patients will need a doctor’s prescription until ACIP releases its recommendations. In Massachusetts, Nevada, and New Mexico, the vaccine will not be available at all until the committee acts.

A CVS spokesperson explained, “A few payers are still updating their systems,” which is causing some of the coverage issues. For now, they advise patients to schedule later appointments if they face coverage problems.

The Centers for Medicare & Medicaid Services (CMS) is actively monitoring the situation. They’ve acknowledged the issues and are working on finding solutions.

This situation underscores the ongoing challenges of vaccine distribution. As experts continue to discuss vaccine policy changes, access to timely and affordable vaccinations remains crucial, especially for vulnerable populations.



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