As last month’s Health News report revealed, on Sept 18 the new Sec of Health and Human Services’ Advisory Committee on Immunization Practices (APIC) issued new rules on COVID vaccination. The APIC left stand, at least for this year, the previous Federal Department of Food and Drug’s (FDA)’s approval for COVID vaccine for those 65 and over and those with at least one health condition making them more at risk for COVID complications. These will be covered by Medicare.
For all others the official vote on COVID vaccination did not mention any specific recommendations. Instead, these Americans were advised that they should engage in “shared decision making” with their doctors, nurses and pharmacists. In a seemingly contradictory additional note, they were advised that they could get the vaccine and don’t need a prescription.
More questions and confusion
Because ACIP did not spell out Yes or No recommendations on vaccines for those who are not at higher risk for COVID complications, the Advisory Committee’s guidance is subject to interpretation. Outside medical organizations, such as the American Academy of Pediatrics (AAP), have voiced concern. Critics argue the new recommendations are vague, create access barriers and could sow distrust in vaccines.
One big area of concern is how the vaccines will be paid for. Traditionally, insurance coverage is determined by APICs recommendations, but without clear recommendations payment responsibility is not clear – Medicare or other government programs, private insurance or self-pay?
The consequences of APIC’s decision are widespread and prompted controversy, concerns and many questions. What follows are six questions and answers clarifying what is known at this time.
Do I need verification that I’ve seen my doctor and was advised to get the 2025-26 COVID vaccine?
That depends on your age and if you have a qualifying health condition, making you more at risk for COVID complications. While discussing COVID vaccination with your doctor is always a good idea, if you are over 65, consulting with your doctor is not required, and Medicare will pay for your vaccine.
If you are younger with a recognized health condition that makes you more at risk of COVID complications, you may have to verify that condition by either self-report or with doctor verification (yet to be determined.)
If you have at least one recognized health condition that makes you more at risk, you may obtain the vaccine (as verified by all three pharmacies).
However, because health insurers rely of APIC recommendations for coverage, and no specific recommendations were made regarding those with higher risk, your insurance may not cover vaccine charges. CDC recommends you check with your employer or insurance carrier to clarify.
What are the recognized health conditions that put me at higher risk?
According to the CDC, health conditions that put an individual at high risk for severe illness from COVID include cancer, heart disease, lung conditions, overweight or obesity, depression and pregnancy, among many other conditions (such as other health conditions more related to lifestyle such as smoking, being sedentary, etc.) At least half of Americans have at least one of these health conditions with some estimates up to 74%. At this point it is not clear how verification of lifestyle-related conditions will be confirmed for COVID Vaccine coverage.
In an apparent contradiction, while pregnancy is on the list of health conditions for high risk, it was not spelled out in APIC’s latest COVID guidelines for eligibility. The American College of Gynecologist (ACOG) has strongly disagreed with this decision, stating “ACOG recommends all women pregnant, planning to become pregnant, or nursing receive a COVID-19 booster or seasonal dose. Pregnant women have historically been at an increased risk of severe disease, adverse pregnancy outcomes, and maternal death from COVID-19 infections.”
Can’t I just go to my local pharmacy like I usually do for my COVID shot?
About 90 percent of COVID-19 shots given in the U.S. during the 2024-2025 season were administered in pharmacies federal data shows. It’s not clear how easy that will be this fall. Access may be dependent on where you live. Nineteen states have laws or regulations that only let pharmacists administer vaccines recommended by ACIP, according to the American Pharmacists Association and since APIC no longer recommends vaccination for all ages, this is a question yet to be resolved. As Brigid Groves, a pharmacist and vice president with the American Pharmacists Association stated “Some pharmacists may be reluctant to give shots to customers who fall outside the usual CDC’s approval range.
Pharmacies may not have the appropriate vaccine for children so vaccination at a doctor’s office may be a better option, although some doctor’s offices, anticipating lowered demand for vaccines may not have adequate supplies, so best to check.
Initially it was feared that some pharmacies could face delays receiving vaccines. However, local pharmacies now have 2025-26 COVID vaccines with walk-up and online registration available.
I’m worried that my healthy, 7-year-old grandson will be exposed to COVID at school. Will his parents be responsible for those vaccine charges to get him protected?
This is a concern many parents have voiced. Insurance coverage is not guaranteed. The financial barrier of needing a doctor visit in addition to the cost of the vaccine may make childhood vaccination challenging, especially for children without higher risk and families with several children.
On a positive note, some insurance carriers are choosing to follow AAP’s recommendation for COVID vaccination for all children, which states that, “Infants and children 6 through 23 months of age are at high risk for severe COVID-19. The AAP recommends all infants and children in this age group who do not have contraindications receive 2025-2026 COVID-19 vaccine…Children 2 through 18 years of age not included in (high risk groups) whose parent or guardian desires their protection from COVID-19 should be offered a single dose of age-appropriate 2025-2026 COVID-19 vaccine.” Source: Policy Statement-American Academy of Pediatrics Committee on Infectious Diseases. It is best to check with the insurance provider regarding coverage.
It takes me 3 months to get in to see my doctor. Isn’t there some other way I can get evidence-based scientific factual advice so I can get expert guidance and information on the COVID vaccine?
For seniors, AARP has published an excellent online guide to COVID vaccines updated to 9/19/2025 which can be accessed under the title: What to Know About Getting a COVID-19 Vaccine This Fall.
Many other reputable medical associations and providers publish expert online information about COVID vaccination such as Mayo Clinic, the American Academy of Family Doctors (AAFD), etc. States too have stepped up to ease the confusion caused by APIC’s guidance. Eighteen states now provide recommendations clarifying COVID access and providing resources. (See online article: “Which states have taken action on COVID-19 vaccine access after FDA, CDC turmoil?”)
In Illinois, Governor JB Pritzker signed an executive order directing the Illinois Department of Public Health (IDPH) and other state agencies to develop consistent vaccine guidance.
When asked if the McHenry County Department of Health (MCDH)will be providing COVID vaccinations this year, Nick Kodiac, Public Information Officer, McHenry County Department of Health, stated “MCDH does not currently have any COVID-19 vaccine available for distribution. Uncertainty surrounding recent federal recommendations has affected supply access.”
Kodiac continued “On September 23, Illinois Department of Public Health (IDPH) Director Dr. Sameer Vohra issued state-specific standing orders recommending the COVID-19 vaccine for adults ages 18 and older. The MCDH supports the IDPH guidelines, as they reflect the best interests of Illinois citizens.”
I’ve had COVID and now that it’s no longer such a health threat, how can I judge if I should get this year’s vaccine?
Choosing to receive a COVID vaccine is, of course, a personal health care decision, ideally guided by consultation with a trusted healthcare provider and informed by knowledge of risk and benefit. Reviewing advice by credible medical experts as listed above makes sense, as well as looking closely at the rampant sources of misinformation now circulating.
For example, consider the risk which has been in the news lately regarding possible myocarditis (inflammation of the heart muscle) after COVID vaccination. Learning more about this is certainly warranted when analyzing vaccine risk and benefits.
The CDC estimated that for every million males aged 12–17 years who took the vaccine, about 56–69 would develop myocarditis (inflammation of heart muscle). However, CDC went on to clarify risks, stating that this number of young males taking the vaccine would prevent 5,700 COVID-19 trans-missions, 215 admissions to the hospital, and two deaths. When assessing risk, it is important to note that studies consistently indicate myocarditis cases are uncommon and typically respond to medication and rest when diagnosed promptly.
Other studies have demonstrated overall cardiovascular risk is significantly lower with COVID vaccination. Example: This July 2024 study involving 36 million people titled “Incidence of stroke and heart attack is significantly lower with COVID vaccination.”
Those considering getting the COVID vaccine should also be aware that COVID remains a public health threat. CCD data released in June shows the virus resulted in 32,000-51,000 U.S. deaths and more than 250,000 hospitalizations last fall and winter. Studies have shown development of long COVID (a serious post-COVID infection) is significantly reduced as well.
The bottom line on the new COVID vaccine recommendations?
To quote Dr. Paul Offit, an internationally-recognized expert in the fields of virology and immunology, and former member of the Advisory Committee on Immunization: “The good news is anyone can get this vaccine. The bad news is no one is encouraged to get it even if you’re in a high-risk group.” In other words, it’s now much more up to you to determine how to protect yourself and those you live with, especially those who may be more vulnerable.
