Does Medicare Cover the Pneumonia Vaccine?
Whether or not it’s flu season, it’s always important to think about preventive care. Pneumonia has varying levels of severity, but a weakened immune system and underlying health conditions can make pneumonia more dangerous for people who are 65 years old 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 pays for 100% of the costs of 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.
Prevnar 20, the pneumonia vaccine developed by Pfizer, is one of the more common shots for pneumonia. This updated vaccine protects against 20 types of pneumonia-causing bacteria.
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:
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 shot, 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. People with certain medical conditions may be more prone to complications. It’s especially important to take preventive measures if you have a vulnerable immune system.
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.
Does your Medicare Advantage plan cover pneumonia shots?
Medicare Advantage plans (also called Part C) 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. Your Medicare Part B coverage includes:
Pneumonia vaccine
Hepatitis B vaccine for people at high risk of infection
Vaccines to treat an injury or exposure to a disease (like tetanus shot)
Your Medicare prescription drug plan (Medicare Part D) covers the following vaccines:
Hepatitis A for people at high risk of infection
Hepatitis B for people at low risk of infection
Medicare has comprehensive coverage of vaccinations—make sure your vaccination history is up to date.
Understanding your Medicare coverage
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.
Frequently asked questions
Passed in 2022, the Inflation Reduction Act protects Medicare beneficiaries by making vaccines and prescription drugs more accessible and affordable. This act requires any vaccines recommended by the CDC to be covered by prescription drug plans. It also stabilizes premiums for Medicare Part D, lowers the cost for the most common medications, and caps your out of pocket costs for drugs for the year.
There are some shots that Medicare doesn’t cover, like certain vaccinations you may need to take before you travel. Secondary insurance such as Medicaid or employer coverage could help you cover these vaccines. If you or your employer contributed to an HSA before enrolling in Medicare, you could use the account to pay for vaccinations that aren’t covered by Medicare as well.
Aside from pneumonia vaccinations, flu shots, and other preventive vaccines, Medicare also covers a number of services for preventive care. From mental health screenings to exams used to detect cardiovascular disease, you can schedule most preventive visits at no cost to you with Medicare.