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Can you get the updated COVID-19 vaccine – and will your health insurance cover the cost?

Author: Louise Norris | Date Posted: September 19, 2025

See if your health plan covers the COVID-19 vaccine

What you can do:

Contact your major medical insurer (throughout this article “health plan”) to confirm that you have coverage for the updated vaccine, and any specific coverage rules that the plan might have. It may come in handy to take notes if you do this over the phone, including the name of the person you spoke to and a reference number for the call.
Ask your health plan if you’ll have any out-of-pocket costs for an office visit required to obtain a prescription for the vaccine, which is being required by some pharmacies.¹
Your plan will likely require you to use an in-network pharmacy or medical office for no-out-of-pocket-cost coverage for the COVID vaccine, so be sure you know where those options are.

Helpful background information:

Most health plans are required to cover the full cost of vaccines recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP),² as part of the ACA’s preventive care coverage.
In June 2025, Secretary of Health and Human Services Robert F. Kennedy, Jr. removed the 17 then-sitting members of ACIP. As of September 15, 2025, Kennedy had appointed 12 new members of ACIP, some of whom had expressed anti-vaccine views.³,⁴
ACIP has not yet made recommendations for the updated 2025-2026 COVID vaccines. The committee is meeting on September 18 and 19.⁵ However, it’s unclear what its recommendations will be for the updated COVID vaccines. (For perspective, the recommendations for the 2024-2025 versions were made by ACIP in June 2024, so they were already in place by the time the FDA approved the updated vaccines in August 2024).⁶

Check your eligibility for the vaccine

The FDA’s approval for the 2025-2026 COVID vaccines is limited to people who are 65 and older, or younger people with health conditions that put them at risk for serious illness from COVID-19.⁷

This means the FDA approval does not apply to people under the age of 65 who have no underlying health conditions. Depending on where you live, the updated FDA approval could make it more complicated to access a COVID vaccine this fall.

Your pharmacy might require a prescription from your doctor before giving you the vaccine, and receiving a prescription is not a guarantee that your plan will cover the vaccine. Until ACIP recommends the 2025-2026 vaccines, pharmacies in some states are requiring prescriptions even for individuals age 65 and older.⁸,⁹

What you can do:

Contact your state’s health department to see if your state has done anything to ensure access to COVID vaccines for someone in your situation. For example, several states, including Colorado,¹⁰ Washington,¹¹ and Massachusetts,¹² have issued standing orders that allow pharmacists to provide COVID vaccinations without individual prescriptions. Other states, including New York,¹³ Pennsylvania, and New Mexico, have also taken actions to make it easier for residents to obtain COVID shots.¹⁴
Contact your pharmacy (making sure to find out whether or not it’s in-network with your health plan), to ask whether they have updated COVID vaccines in stock, and whether they have any restrictions on who can receive the shot.
Depending on where you live, the pharmacy might tell you that you need a prescription from your doctor before they can give you a shot, or they might tell you that they can’t give you the shot until ACIP recommends it. If that’s the case, your next step should be to call your doctor’s office to see if they’ll write you a prescription or if they can simply give you the shot in their office. Once you have this information, contact your insurer to understand whether your vaccine is covered by your insurance and to what extent.

Helpful background information:

Local pharmacies have historically administered the large majority of COVID-19 vaccines,¹⁵ and they’ve been widely available to anyone over six months of age.¹⁶ But with the new FDA guidelines and the lack of ACIP recommendations, getting a COVID shot at a pharmacy — and the question of whether health plans will cover the shot — might be more complicated this year.

Keep trying to get access to the vaccine

If you can’t get a COVID vaccine when you first try, know that this situation is rapidly evolving. Your access might change in the coming days and weeks, due to state actions or changes in federal guidance. If and when ACIP makes recommendations for the updated vaccine, access should become easier for groups that are within the FDA approval and also within whatever recommendations ACIP makes.

ACIP’s recommendation is particularly important in terms of health coverage, as the recommendation sets the minimum requirements for what health plans have to cover with no out-of-pocket costs. So if, for example, ACIP’s recommendations were to align with the updated FDA approval (in other words, for those 65 and older, and younger people with underlying health conditions), that could affect health coverage moving forward, as health plans would not be required to cover the vaccine for other populations.

But health plans can also provide coverage beyond the minimums set by ACIP’s recommendations. AHIP, a health insurance trade organization that represents health plans that cover more than 200 million Americans, announced in late June that they are “committed to ongoing coverage of vaccines to ensure access and affordability for this respiratory virus season.”¹⁷ And in mid-September, AHIP went a step further, saying “Health plans will continue to cover all ACIP-recommended immunizations that were recommended as of September 1, 2025, including updated formulations of the COVID-19 and influenza vaccines, with no cost-sharing for patients through the end of 2026.”¹⁸

Although AHIP represents the health plans that cover the majority of Americans, their statement should not be taken as a blanket guarantee. Consumers should still check with their plan to confirm coverage, particularly if ACIP were to scale back the current vaccine recommendations.

Regardless of what ACIP recommends, states can enact laws and adopt regulations that require health plans to cover the full cost of COVID vaccination. Some states have already taken steps to do this, including, for example, Massachusetts¹⁹ and Colorado.²⁰

But while the ACA’s preventive care mandate – including coverage for ACIP-recommended vaccines – applies to self-insured group plans, state insurance mandates do not apply to self-insured plans.²¹ And the majority of people with employer-sponsored health insurance are covered under self-insured plans that thus aren’t subject to these state mandates.²²

Frequently asked questions about COVID-19 vaccinations

Will my doctor prescribe the COVID vaccine if I’m not in the FDA-approved populations?

This will depend on your doctor. Prescribing a drug for something outside of its FDA approval is referred to as an “off-label prescription.” This is legal, and about 20% of prescriptions are off-label.²³

If your doctor won’t write the prescription and your pharmacy won’t give you the shot without a prescription, you can contact your health plan to confirm whether the vaccine is covered, and if so, see if they can provide any guidance for how you could obtain it.

Where can I get a COVID vaccine if my health plan won’t pay for it?

If your health plan won’t pay for a COVID vaccine, first check with your state insurance department to ensure that the plan is allowed to refuse the coverage. If so, you can check with your state health department to see if there are any public health clinics in your area where you can get a low-cost or free COVID vaccine.

Alternatively, you can choose to pay out of pocket for the vaccine at your local pharmacy, but be aware that the cost without health insurance will likely be at least $140 for an adult dose.²⁴ (And as is always the case when you pay out-of-pocket for something that’s not covered by your health plan, the money you spend will not count toward your deductible or your out-of-pocket maximum.) If you have flexible spending account (FSA) or health savings account (HSA) funds available, you can use that pre-tax money to pay for a COVID vaccine.²⁵

When will ACIP make vaccine recommendations for 2025-2026?

ACIP is meeting September 18 and 19, to discuss recommendations for several vaccines, including COVID, Hepatitis B, measles, mumps, rubella, varicella (MMRV) and Respiratory Syncytial Virus (RSV).²⁶

Senator Bill Cassidy, M.D. (R-LA), who chairs the Senate Health, Education, Labor, and Pensions (HELP) Committee, had called for the meeting to be postponed, and noted that if it went ahead (as was the case), any recommendations should be “rejected as lacking legitimacy,” due in part to the “current turmoil in CDC leadership.”²⁷ But no changes had been made to the ACIP meeting schedule as of Sep. 8.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.