Is Pneumococcal Vaccine Covered by Medicare?

Pneumococcal disease, which can lead to serious infections like pneumonia, meningitis, and bloodstream infections, poses a health risk, particularly for older adults. Vaccination offers protection against these outcomes. Medicare provides coverage for pneumococcal vaccines, recognizing their importance in preventive healthcare. This coverage helps beneficiaries access protection without substantial financial burden.

Medicare Coverage for Pneumococcal Vaccines

Medicare Part B, which covers medical insurance, includes pneumococcal vaccines as a preventive service. Both the vaccine and its administration are covered. Medicare’s coverage aligns with recommendations from the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP). These recommendations outline the types and sequence of pneumococcal vaccines for adults, especially those aged 65 and older.

Two main types of pneumococcal vaccines are available: the pneumococcal conjugate vaccine (PCV), which includes variations like PCV13, PCV15, and PCV20, and the pneumococcal polysaccharide vaccine (PPSV23). For individuals aged 65 and older who have not previously received a PCV, the CDC recommends either one dose of PCV20 or a two-dose regimen of PCV15 followed by PPSV23. The PPSV23 dose is administered at least one year after the PCV15 dose.

Medicare covers an initial pneumococcal vaccine for beneficiaries who have never received one. A different, second pneumococcal vaccine is also covered if administered at least one year after the first vaccine. For instance, if a beneficiary aged 65 or older received PPSV23 previously, PCV13 or a newer PCV vaccine may be recommended at least one year after the last PPSV23 dose. The specific vaccine type and sequence depend on an individual’s vaccination history and the latest ACIP guidance.

Costs and Patient Responsibilities

For Medicare beneficiaries, the financial responsibility for pneumococcal vaccines is minimal. If the vaccine is received from a healthcare provider who accepts Medicare assignment, beneficiaries pay $0 for both the vaccine and its administration. This is because pneumococcal vaccines are classified as a preventive service under Medicare Part B.

The Part B deductible and coinsurance do not apply to these preventive services. This means beneficiaries will not incur out-of-pocket costs such as a yearly deductible or a percentage of the Medicare-approved amount. Medicare Advantage plans also cover pneumococcal vaccines with no out-of-pocket costs, provided the beneficiary uses an in-network provider.

A cost may be incurred if a provider does not accept Medicare assignment, or if additional services are rendered during the visit that are not part of the preventive vaccine administration. For example, if a doctor addresses other health concerns during the same visit as the vaccine, separate charges for those services may apply, subject to standard Part B deductibles and coinsurance. Confirm with the provider that they accept Medicare assignment to ensure full coverage for the vaccine.

Getting Your Pneumococcal Vaccine

Obtaining your pneumococcal vaccine is accessible for Medicare beneficiaries. You can receive the vaccine at various locations, including your doctor’s office, local clinics, and many pharmacies. These locations administer the vaccine and process Medicare coverage.

When you get your vaccine, bring your Medicare card. This card provides information for the provider to verify eligibility and process the claim directly with Medicare. Before receiving the vaccine, confirm that the healthcare provider or pharmacy accepts Medicare assignment. This ensures you will not have any out-of-pocket costs for the vaccine and its administration.

If you have a Medicare Advantage plan, verify that the provider is part of your plan’s network to ensure full coverage. While no physician’s order is required for the vaccine, discussing your vaccination history with your doctor helps determine which pneumococcal vaccine is most appropriate for you based on current recommendations.