Timing and cost of new vaccines vary by virus and health insurance status

COVID-19 and flu boosters and the new RSV vaccine are all recommended this year

By: - August 28, 2023 6:00 am

(Commonwealth of Pa. photo).

As summer edges toward fall, thoughts turn to, well, vaccines.

Yes, inevitably, it’s time to think about the usual suspects — influenza and COVID-19 shots — but also the new kid in town: recently approved vaccines for RSV, short for respiratory syncytial virus.

But who should get the various vaccines, and when?

“For the eligible populations, all three shots are highly recommended,” said Georges Benjamin, a physician and the executive director of the American Public Health Association.

Still, there’s no need to get them all at the same time, and there are reasons to wait a bit for two of them. Some people may also face cost issues. Let’s break this down.

What’s the Price?

It depends on the vaccine — and on your insurance coverage.

For COVID shots, including the updated ones expected to be available this fall, most people will still be able to get the vaccines for free. People became accustomed to that no-cost availability during the pandemic, but the federal government stopped picking up the entire tab with the end of the public health emergency this spring.

Now the actual cost of the vaccine, which manufacturers said could be far higher than what the government paid during the pandemic, will be borne by private insurers and Medicare and Medicaid. For people without insurance, the Biden administration set up the Bridge Access Program, which will make free vaccines available this fall through community health centers and state health departments. Eventually, retail pharmacies may also participate.

Pfizer and Moderna, two of the companies producing updated COVID vaccines, previously suggested they would charge $110 to $130 per dose, and plan to offer programs for people who cannot afford the vaccines. In July, the Biden administration urged both makers to set a “reasonable” rate for the updated versions. Another company, Novavax, has said it will also have an updated vaccine for the U.S. market. It is still unclear how prices will shake out. In a recent Moderna earnings call, company officials indicated they are negotiating contracts with payers but did not give per-dose figures. The company expects COVID vaccine sales worldwide to tally $6 billion to $8 billion this year.

The Affordable Care Act says patients don’t have to pay for certain preventive care, including some vaccines. That means flu shots are offered at no cost to people with insurance, including those on Medicare and Medicaid. Those without insurance may be able to land a free or low-cost shot from some health centers and state health departments. The cost of the flu vaccine depends on the type of shot and the pharmacy or medical outlet providing it but can range from $20 to more than $70.

Updated COVID-19 vaccines expected to be available in September, federal officials say

Similar rules apply to the new RSV vaccines, which may carry a price tag between $180 and $295 a shot. Because they are recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, they are covered for people with private insurance without a copay. The Inflation Reduction Act did the same for Medicare beneficiaries and provided incentives for states to follow suit with Medicaid. Still, Medicare beneficiaries should note that the RSV vaccine is covered under Part D of the program, so those who have not signed up for the drug benefit may have to pay out-of-pocket.

It may take a while for insurers to list the RSV vaccine on their formularies, so patients are advised to check their health plans before making an appointment.

The uninsured, however, will need to turn to low-cost clinics or health departments, although those programs may vary.

Such lack of access “means we will have another health disparity for people who can’t afford it,” said Benjamin, of the public health association.

Luckily, most of those seeking the shot are likely to be on Medicare, which will cover it, he said. “But if you are 60 to 65 and not yet on Medicare, you might have some challenges.”

RSV Vaccines

The newest of the vaccines target RSV, a common respiratory illness. The season for RSV infections usually begins in the fall and lasts into the spring, potentially peaking in January and February.

The CDC estimates that 60,000 to 160,000 people 65 and older are hospitalized because of RSV annually, with approximately 6,000 to 10,000 deaths among that age group. Infants and older adults are most at risk.

Risk factors for having a more severe case include increased age, but also underlying conditions like lung diseases, cardiovascular problems like congestive heart failure, diabetes, and kidney and liver disorders, and being immunocompromised. The illness can also aggravate existing conditions such as asthma and chronic obstructive pulmonary disease.

The two new vaccines have been approved for older adults, with the CDC’s vaccine advisory panel saying people 60 or older should be able to get one of them if they and their doctor or other medical provider agree it would be a good precaution.

If you fall into those categories, don’t wait too long, said William Schaffner, a physician and professor of preventive medicine at Vanderbilt University. “That’s one you can do and get out of the way right now.”

Those who get one of the new RSV vaccines now should take a brief pause of at least two weeks before getting any other vaccination because there isn’t much data on whether they interact with other shots when received concurrently, he said.

The effectiveness of the RSV vaccines in preventing severe disease is expected to remain high through this year’s RSV season, and they may also provide some protection the following year, based on information from the clinical trials.

In early August a new monoclonal antibody, which contains lab-made antibodies against RSV, was approved for infants under 8 months and certain other young children, and it should be available soon. The shot is similar to a vaccine, but it works faster because it supplies the antibodies itself rather than spurring a baby’s immune system to produce them. Among children under 5, RSV causes 58,000 to 80,000 hospitalizations and 100 to 300 deaths each year, according to the CDC. On Monday, the FDA approved Pfizer’s RSV vaccine to be given during pregnancy to convey protection to infants after they are born until they are 6 months old. It isn’t yet known when the vaccine will become available or the specific recommendations the CDC will make about who should get it.

As with any drug or vaccine, side effects are possible with any of the new shots, including pain at the injection site, headache, fatigue, and some other, rarer side effects.

“It’s always good to sit down and talk with your doctor. They know your medical history,” said Mahdee Sobhanie, an infectious diseases physician at the Ohio State University Wexner Medical Center.

COVID and Influenza Vaccines

Both COVID  and flu shots are worth getting, but it might be a good idea to wait a little bit.

One reason is that updated COVID shots awaiting approval are formulated to work against strains more commonly circulating now, known as the XBB lineage. The boosters will not directly target the new “Eris” variant currently rising in the U.S., though Eris is considered a descendant of XBB.

If approved, the updated vaccines are expected to become available around late September.

When to get vaccinated can be confusing, with the seasonality of the illnesses varying a bit. Flu season usually starts in late fall and runs into spring. We have fewer years’ data on COVID, but it appears to vary with the seasons, too, with upticks in winter when people gather inside, but also during hot summer months, when people are more likely to seek air-conditioned indoor venues.

With the updated COVID vaccines expected in the next couple of months, patients should be able to get a COVID vaccination and an influenza shot at the same time, said Schaffner.

“We have good info they don’t interact,” he said.

The influenza vaccine is designed to last through the season, but effectiveness can wane. For that reason, even though you might start seeing ads in August, many experts suggest waiting until the end of September or early October to get a flu shot.

“If you get it too early, it might not cover you too well toward the end of the season,” Schaffner said.

This article first apppeared on KFF Health News, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Our stories may be republished online or in print under Creative Commons license CC BY-NC-ND 4.0. We ask that you edit only for style or to shorten, provide proper attribution and link to our web site. Please see our republishing guidelines for use of photos and graphics.

Julie Appleby
Julie Appleby

ulie Appleby, Senior Correspondent, reports on the health law’s implementation, health care treatments and costs, trends in health insurance, and policy affecting hospitals and other medical providers. Before joining KFF Health News, Julie spent 10 years covering the health industry and policy at USA Today. She also worked at the San Francisco Chronicle and the Contra Costa Times in Walnut Creek, California. She helped launch the Association of Health Care Journalists’ Awards for Excellence in Health Care Journalism contest in 2004 and oversaw it for more than a decade while serving on the association’s board. She holds a master’s degree in public health.

MORE FROM AUTHOR