Moderna Flu Shot Hitters Face $40 Co-Pay as HHS Leaves Advisory Committee Empty

Ron Kroening paid a $40 co-pay for the Moderna mRNA flu vaccine in late October, a cost he had never previously incurred for an annual flu shot. Kroening, 63, received the recommendation from his doctor due to asthma and seasonal allergies. The vaccine, approved by the FDA in August for adults 50 and older, offers stronger protection than traditional shots according to clinical trials. Kroening discovered the cost after locating the only local pharmacy with stock.

His insurer explained that the vaccine is not covered because it lacks a recommendation from the Advisory Committee on Immunization Practices, or ACIP. Under current regulations, insurers are not mandated to cover new vaccines until they are formally recommended by the committee. Because the committee is currently empty, the new flu shot falls into a coverage gap.

The ACIP has been in limbo since Health and Human Services Secretary Robert F. Kennedy Jr. replaced its expert members with handpicked allies. A federal judge halted these changes in 2025, ruling that the process was flawed. Kennedy has since cut childhood immunization recommendations by a third but has not nominated new members to the committee. As a result, no new vaccine recommendations are being issued despite ongoing FDA approvals.

The delay creates a specific financial penalty for patients. Insurers generally have one year from an ACIP recommendation to implement coverage by the next plan year. If the committee recommends the Moderna shot in December 2026, coverage is required by January 2028. If the recommendation slips to January 2027, the mandate does not take effect until January 2029. Experts note that this timeline is likely, given the committee's current state.

Lindsay Wiley, a professor at UCLA Law, noted that the legal requirement for coverage moves slowly. She stated that while a recommendation might come next year, there is no reason to think it will happen soon. The delay is effectively pushing the mandatory coverage date further into the future. Only the 15-day window for COVID-19 vaccines, established by the Affordable Care Act, provides a faster coverage pathway.

The absence of a functioning ACIP affects access beyond just cost. Some states prohibit pharmacists from administering vaccines without a formal ACIP recommendation. Previous committee decisions, such as the September 2025 recommendation for RSV shots, have been halted by court order, though insurers continue to cover them. The committee's voided vote to end the universal birth dose of the hepatitis B vaccine is also influencing state-level legislation.

Delays are also reported for Medicare, which covers new flu shots for seniors by law regardless of ACIP status. Aaron Siri, a lawyer who previously represented Kennedy, wrote on Monday that the White House and Department of Justice are making no serious attempt to revive the committee. He argued that the federal government is actively preventing a functioning advisory body from operating.

Dorit Reiss, a vaccines expert at UC Law San Francisco, agreed that the federal government is choosing not to install a new ACIP. She observed that Kennedy's original slate of advisers appeared uninformed about vaccine policy during public meetings. Reiss noted that keeping the committee dormant allows Kennedy to bypass the slow process of formal committee approval and potentially issue his own recommendations directly.

Kroening’s insurer is part of AHIP, an industry group that pledged to continue covering all shots recommended as of September 2025. Insurers retain the option to cover vaccines before they are legally required to do so. Kroening said he chose the new vaccine despite the co-pay because he believes it is more cost-effective than treating the flu.

Kroening remains concerned about the future of immunizations in the United States. He described the current situation as a mess, noting that vaccines are becoming harder to access. The court case challenging the committee's dissolution continues, with the government appealing the portion of the order that disbanded the group.