Pneumonia has varying levels of severity, but a weakened immune system and underlying health conditions can make pneumonia more dangerous for people aged 65 and up. The pneumonia vaccine can lessen your symptoms and protect you from hospitalization, respiratory failure, and serious issues caused by pneumonia-causing bacteria. 

Medicare Part B fully covers the pneumonia vaccine. You’ll pay absolutely nothing for the shot if your healthcare provider accepts assignment for the service. 

Key takeaways:

  • Medicare Part B fully covers the pneumonia vaccine.

  • Medicare Advantage plans cover the pneumonia vaccine, but you may be responsible for an out-of-pocket cost if you see an out-of-network provider. 

What is the pneumonia vaccine?

Pneumonia is an inflammatory condition that affects the lungs. It can be caused by various things, including bacteria, viruses, fungi, and parasites. The most common cause of bacterial pneumonia is the Streptococcus pneumoniae bacteria (which can cause meningitis and ear infections). The pneumonia vaccine helps your body develop antibodies against common types of the pneumococcal disease. Below, we explain more about how pneumonia affects your body, how the vaccine can help, and how coverage for the pneumonia vaccine works. 

How pneumonia works in the body

You can breathe in and “catch” a pneumonia-causing pathogen, like bacteria, through droplets in the air. If your immune system isn’t able to fight the bacteria off, air sacs in your lungs can fill with fluid, making it harder for you to take in oxygen. This can cause a cough, fever, chest pain, difficulty breathing, and chills. In more severe cases, pneumonia can lead to respiratory failure and sepsis (when an infection damages other parts of your body). 

Populations at risk for pneumonia 

Older adults are more likely to have weakened immune systems and chronic health conditions. Developing pneumonia is much more serious for this population because it becomes more difficult for your body to fight off the pathogens. 

Your risk of hospitalization due to pneumonia increases if you have:

  • Asthma

  • Chronic obstructive pulmonary disorder (COPD)

  • Congestive heart failure

  • Cystic fibrosis

  • Dementia

  • Diabetes

  • Liver or kidney disease

  • Recently had respiratory infection

  • A weaker immune system due to chemotherapy, HIV/AIDs, or other factors

You can’t always predict when pneumonia occurs. Some people even catch pneumonia after being on a ventilator or during a hospital stay. For this reason, it’s important to take preventative measures. Since Medicare pays for the pneumonia vaccine, there’s not much standing in your way of getting vaccinated.

How does the pneumonia vaccine work?

Vaccinations provide the best preventive medicine to protect against pneumonia infections. There are a few different types of pneumonia vaccines. Don’t worry about determining which of these vaccines is right for you. Your healthcare provider will make this decision. 

  • PCV15 - recommended for children and adults who’ve never received a PCV

  • PCV20 - recommended for children, adults, and anyone who received PCV13

  • PPSV23 - recommended for people who previously received PCV15

  • PCV7 and PCV13 - earlier versions of PCVs

Each of these vaccines help protect you from the most common and serious types of pneumococcal disease. Getting the vaccine does not, however, eliminate your chances of developing an infection. Once you receive the vaccine, you’ll usually have some protection after about three weeks.

Pneumonia treatment

If you do catch pneumonia, doctors typically treat it with antibiotics. For certain cases caused by a virus, your healthcare provider can prescribe antiviral medications, over-the-counter medications, or supplemental oxygen therapy. 

Does Medicare cover the pneumonia vaccine?

Medicare Part B and Part D are both responsible for covering different types of vaccines.  

Medicare Part B covers the pneumonia vaccine, also called pneumococcal shots. You can receive the vaccine as a single dose or in 2 doses. Medicare Part D covers your prescription drugs. In 2023, Medicare drug plans expanded coverage to include free shots for most CDC recommended vaccines, like shingles, RSV, and Tdap

How to get the pneumonia vaccine through Medicare

You won’t have to pay anything if your healthcare provider accepts Medicare assignment for administering the vaccine. Your doctor’s office, local pharmacy, clinic, or community health center should all accept Medicare.

Medicare Advantage plans also cover the same services as Original Medicare. You shouldn’t have to pay for the pneumonia vaccine with a Medicare Advantage plan. However, you may have out-of-pocket costs if you get the shot from an out-of-network provider. 

Other vaccines that Medicare covers

Medicare beneficiaries have comprehensive vaccine coverage for preventative care. Medicare Part B covers:

Your prescription drug coverage (Medicare Part D) covers the following vaccines:

  • Shingles

  • Tdap

  • RSV

  • Hepatitis A for people at high risk of infection

  • Hepatitis B for people at low risk of infection 

If you’re ever confused about what Medicare covers, we’re here to help. Medicare is not always the easiest to navigate—our Medicare Advisors and Advocates can help you understand all aspects of your plan and get you the coverage you need. Call us at 855-900-2427 or pick a time to chat for free, personalized support.

Get Medicare, Maximized