As federal health agencies prepare to roll out updated Covid-19 vaccines this fall, some Americans may find themselves facing unexpected bills for a shot that was once universally covered.
The Food and Drug Administration (FDA) is expected to authorize the next round of Covid boosters, but this time only for high-risk groups — adults 65 and older and people with certain medical conditions. The Centers for Disease Control and Prevention (CDC) is likely to align with that decision, narrowing its recommendations from the current guidance, which advises vaccination for everyone 6 months and older.
This shift could directly influence insurance coverage. By law, health plans must cover vaccines recommended by the CDC and its Advisory Committee on Immunization Practices (ACIP) at no cost to patients. But for people outside the high-risk categories, whether the Covid shot is free, requires a copay, or isn’t covered at all will depend on individual insurance providers. Without coverage, a dose can cost up to $140, according to CDC estimates.
“It could very well get confusing,” said Dr. William Schaffner, an infectious disease expert at Vanderbilt University Medical Center and ACIP adviser. “Whether you get a free shot may greatly depend on which company provides your insurance.”
Who Will Be Eligible?
While healthy children and adults won’t be prohibited from receiving the vaccine, their coverage may be inconsistent. “It’s legal to give a vaccine off-label,” explained Dorit Reiss, a vaccine policy expert at UC Law San Francisco. “Insurance companies can choose to cover them.”
A spokesperson for AHIP, the health insurance trade group, said individual insurers will set their own policies once the CDC issues final recommendations. Many companies also consider guidance from professional medical groups, such as the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics (AAP).
The AAP this week reaffirmed its support for vaccinating children against Covid, even as federal recommendations narrow.
How Quickly Will Coverage Change?
For most private health plans, including Affordable Care Act marketplace plans, coverage changes tied to ACIP recommendations typically take effect in the next benefit year, beginning January 1. This means individuals may still be covered for a fall booster in 2025 before new rules apply. Medicare and Medicaid, however, adopt ACIP guidance immediately once the CDC director signs off.
Insurance companies are signaling mixed approaches. Blue Cross Blue Shield said its regional plans will decide coverage individually. Aetna confirmed that children and pregnant women will continue to receive the booster at no cost, but added that coverage for healthy adults may vary depending on their plan.
Impact on Seasonal Vaccinations
The changes could also complicate efforts to encourage people to receive both Covid and flu shots at the same time, a strategy increasingly popular during peak respiratory virus season.
Dr. Schaffner warned that confusion about eligibility or costs could discourage people from getting vaccinated at all. “We have to reassure those at high risk that the vaccine will be available to them,” he said.
Pharmacy chains say patients are unlikely to be blindsided. Rick Gates, chief pharmacy officer at Walgreens, said pharmacists confirm insurance coverage before administering vaccines, informing patients in advance whether the shot is free, requires a copay, or must be paid out of pocket.
Gates noted that while many customers are already receiving flu shots, many are waiting for the updated Covid vaccine to become available. Last season, more than half of Walgreens patients opted to receive both vaccines during the same visit, a trend that has steadily grown over the past few years.
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