Does Medicare Cover the Pneumonia (Pneumococcal) Vaccine?
This article was updated on: 09/12/2018
The pneumonia shot (also called pneumococcal vaccine) is a standard recommendation for anybody who is 65 or older, according to the U.S. Centers for Disease Control and Prevention, or CDC. Incidentally, it’s also recommended for children who are under five years old and anybody else with certain health conditions that would cause doctors to consider them at a higher risk for developing pneumonia.
How pneumococcal vaccines work
Streptococcus pneumoniae is a kind of bacteria that causes pneumococcal disease. Besides pneumonia, this bacteria may also cause other serious diseases that include meningitis and bacteremia, according to the National Foundation for Infectious Diseases. All of these diseases have been associated with high fatality rates, particularly in vulnerable populations. The bacteria can spread through respiratory droplets (for example, sneezing).
The CDC says that there are currently two vaccines that have been approved for use to help you develop an immunity to this bacteria:
- Pneumococcal polysaccharide vaccination PPSV23: This vaccine is commonly suggested for adults over 65 or with certain risk factors.
- Pneumococcal conjugate vaccination PCV13:This vaccine is recommended for adults who are over 65.
In some cases, the CDC recommends a second dose of PPSV23, but at least five years should elapse between doses. Also, both vaccines may be recommended for certain adults with risk factors for developing one of the diseases.
Medicare coverage for the pneumonia shot
Part B of Original Medicare does cover the pneumonia vaccine, but there are certain limitations, according to Medicare.gov:
- Medicare Part B covers one shot. Anybody who is enrolled in Part B is entitled to a dose of pneumonia vaccine without having to pay for it if your health-care provider accepts Medicare assignment.
- Under certain circumstances, a doctor may prescribe a second shot of a different typeat least one year after the first dose. Part B may also cover this second dose.
- In either situation described above, you typically won’t have out-of-pocket costs as a Part B beneficiary.
In some cases, a doctor may recommend more doses than the amount that Part B pays for. For example, a doctor may suggest a second dose of the PPSV23 vaccine. In this case, it’s possible that a Medicare Supplement or Medicare Advantage plan will provide coverage. Otherwise, you might have to pay for these additional services out of pocket. If the cost is a concern, it’s a good idea to contact Medicare or your Medicare plan to learn how these additional services will be covered or if they will be covered at all.
How to learn more about Medicare coverage for pneumonia vaccines and other preventative services
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