Does Medicare Cover the Pneumonia Vaccine?

Does Medicare Cover the Pneumonia Vaccine

Medicare covers a variety of vaccinations at no cost to you, including the pneumonia, or pneumococcal vaccine.

Medicare does cover the Pneumonia vaccine, but the exact conditions will vary. Usually, Medicare will provide full coverage for two doses of the vaccine, but the situation can be different if you have a Part C Medicare Advantage Plan. We’ll go through all of the details here, so you can know what to expect.

What Exactly Is the Pneumonia Vaccine?

The Pneumonia vaccine is more accurately referred to as a pneumococcal vaccine, which provides immunity for a variety of diseases. Pneumococcal vaccination protects from pneumonia, meningitis, and other related conditions.

The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices notes that the vaccine should be taken by children under 2, as well as adults over 65 years of age. This last category notably includes most Medicare beneficiaries.

What Types of the Vaccine Are There?

Like some other vaccines out there, there is more than one type of pneumococcal vaccine. The main varieties are known as PCV13 and PPSV23. PCV13 stands for pneumococcal conjugate vaccine, while PPSV23 is stands for pneumococcal polysaccharide vaccine. The numbers reflect the number of bacterial strains that the vaccine protects against: 13 and 23 respectively

Usually, it is suggested that children under 2 receive the PCV13 vaccine, while seniors receive the PPSV23 vaccine. However, your doctor will let you know which vaccine you need to take, as some people with certain conditions have different needs. Medical advice should be received only from your doctor.

How Often Can I Get the Vaccine?

Medicare will pay for your vaccination under your Part B coverage. You will be able to get two vaccinations: one at any time you choose, and another fully covered vaccination at least one year after the first.

If your doctor notes that you need another pneumococcal vaccination, you may need to pay some or all of the cost associated. If this is the case, make sure you understand how much you will have to pay beforehand, if possible.

You will only receive full coverage for your pneumococcal vaccination if your doctor accepts Medicare assignment. This means that they charge only the Medicare-approved amount for their services, which results in no excess charges. If you’re unsure whether or not your doctor accepts Medicare assignment, they should be able to tell you.

What Parts of Medicare Cover the Vaccine?

Many vaccines are covered by Medicare Part D, which offers prescription drug coverage. However, Part D prescription drug coverage usually won’t cover something that’s already covered by Part B medical insurance. Pneumonia shots are covered by Part B, but remember that many other vaccinations are covered by Part D instead.

Pneumonia Shots Under Part A

Part A of Medicare refers to your hospital insurance. More accurately, it offers coverage in an inpatient setting. It’s very uncommon to receive a vaccination in a hospital setting, so this shouldn’t ever come up.

However, if you do get a pneumococcal vaccine shot in a hospital for some medically-necessary reason, it may be covered under Part A instead of Part B. However, you will probably have to discuss the details more directly with Medicare if this happens.

Part B: Your Main Coverage

As we noted earlier, Medicare Part B covers your pneumonia vaccine. Part B also covers a few other vaccinations: influenza (the flu), H1N1, also known as swine flu, and the Hepatitis B vaccine are all covered by Part B. Part B will also usually cover vaccinations that are situation-specific. For example, if you are bitten by an animal and need a rabies vaccine, it will be covered by Part B.

Part C: Vaccination with Medicare Advantage

Medicare Advantage plans, also known as Part C plans, are private insurance plans that are available to Medicare beneficiaries. Medicare Advantage plans are required by law to provide at least the same coverage that Original Medicare (Parts A and B) covers. For this reason, Medicare Advantage will offer you the same pneumococcal vaccination coverage that Part B does.

There are two variations to be aware of. Part C plans are allowed to provide more coverage than Original Medicare, but not less. This means that your Part C plan may offer even more vaccination coverage than Original Medicare does.

The other variation is that Part C plans usually have provider networks. In this case, your services will only be fully covered by doctors in your network. In this situation, make sure that you receive your vaccination from a doctor that you know accepts your plan.

Part D Prescription Drug Plans

Part D plans cover most preventive vaccines that you could need to receive. Although Part B covers a few vaccines noted above, most of your vaccine needs will be covered by Part D plans. Part D plans, like Part C plans, are offered by private insurance companies. This means that you will have a provider network as well as a unique formulary that tells you how much each drug-related service will cost.

You won’t need a Part D plan to get your pneumococcal vaccine.

Can Medigap Plans Help?

Medigap plans, also known as Medicare Supplement Plans, help pay for some of your out-of-pocket Medicare costs. These plans don’t directly pay for health care, but rather pay for things like your copayment, coinsurance, deductible, and excess charges.

If your vaccine is received from a health care provider who doesn’t accept Medicare assignment, then you may have to pay excess charges. In this case, a Medigap plan may help cover these charges, depending on which plan you have. However, Medigap plans will never directly cover your vaccine.

Who Should Get the Vaccine?

To answer this question, first and foremost you should speak to your doctor. There is no substitute for professional medical advice, so this information will just refer to who usually gets the vaccine.

The pneumococcal vaccine is usually given to very young children or seniors. This is because these populations are usually most susceptible to pneumococcal diseases. If you receive Medicare benefits, you should talk to your doctor about getting vaccinated as soon as you can.

How Much Does the Vaccine Cost?

The pneumococcal vaccine will usually cost somewhere between $90 and $150 if you pay out-of-pocket. This entire cost will be covered by Medicare Part B health insurance for the first two doses that you receive. After this, you may have to pay the entire cost out of pocket, or just pay a portion depending on the specific details of your situation.

Pneumococcal Vaccines: What to Remember

Overall, pneumococcal vaccines should be easy to receive. Your vaccines will usually be covered unless you receive it more than twice or in quick succession, and the coverage is easy to receive with Original Medicare since you have no provider network or other restrictions. The important thing is to schedule for the vaccine as early as possible.

Additional Resources

Kolt Legette
Since 2003, Kolt Legette has helped clients navigate the often-confusing world of insurance. His number one goal is protecting the medical and financial wellbeing of every person he speaks with, whether they choose to buy insurance or not. Kolt loves representing the best brands in medical insurance as it allows him to provide side-by-side comparisons for his clients. This allows the client to decide which company works best for them. By putting the needs of the client above everything else, Kolt helps real people find affordable health insurance solutions for their most pressing healthcare needs. With his belief that peace of mind is priceless, Kolt's goal in every interaction is to make sure each person he speaks to leaves with the peace of mind they rightfully deserve.


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