Does Medicare Cover Pneumonia Shots?

Pneumonia is a lung infection that poses a significant health risk, particularly for older adults. Vaccination offers protection against this illness, which can lead to serious complications. Fortunately, Medicare covers pneumonia shots, ensuring beneficiaries can access this important preventive measure.

Coverage Under Medicare Part B

Medicare Part B serves as the primary source of coverage for pneumonia vaccines. This part of Medicare covers medically necessary services, including preventive care. The Centers for Disease Control and Prevention (CDC) recommends pneumococcal vaccination for adults aged 65 and older, and Medicare Part B covers these shots.

Part B generally covers two types of pneumonia vaccines: a pneumococcal conjugate vaccine (such as PCV13, PCV15, or PCV20) and a pneumococcal polysaccharide vaccine (PPSV23). For individuals aged 65 and older who have not previously received a pneumococcal conjugate vaccine, the recommendation is typically one dose of PCV20, or a two-dose regimen involving PCV15 followed by PPSV23, often administered at least one year later. These vaccines are considered preventive services, meaning beneficiaries typically incur no out-of-pocket costs, including no deductible or copayment, as long as the healthcare provider accepts Medicare assignment. These vaccines must be administered by a doctor or other qualified healthcare provider who participates in Medicare.

Coverage Under Medicare Part D

While Medicare Part B primarily covers pneumonia shots, Medicare Part D plans may cover certain vaccines not covered by Part B. Part D plans focus on prescription drug coverage, including most other vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). For routine pneumonia vaccines, Part D coverage is generally an exception, occurring only if Part B does not cover the shot for a specific reason.

If a pneumonia vaccine falls under Part D coverage, beneficiaries might face associated costs. These could include deductibles, copayments, or coinsurance, which vary based on the specific Part D plan. Individuals should consult their specific Part D plan’s formulary to understand potential costs and coverage details.

Medicare Advantage Plan Considerations

Medicare Advantage Plans, often referred to as Part C, are offered by private companies approved by Medicare. These plans are required to provide the same benefits as Original Medicare, including coverage for pneumonia shots. Therefore, beneficiaries enrolled in a Medicare Advantage Plan will typically receive the same no-cost coverage for pneumonia vaccines as those with Original Medicare Part B.

Medicare Advantage plans often have specific rules regarding where services can be obtained. Beneficiaries may need to utilize in-network providers, pharmacies, or clinics to ensure full coverage. It is advisable for individuals with a Medicare Advantage Plan to contact their plan administrator directly to confirm network requirements and any specific procedures for receiving their pneumonia shot. While some Medicare Advantage plans may offer additional benefits beyond those of Original Medicare, the core coverage for pneumonia shots will align with the no-cost provision of Part B.