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Does Medicare Cover Pneumonia Shots

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What Is The Pneumonia Vaccine

Medicare & You: Vaccines

There are currently two types of pneumococcal vaccines that cover different strains of a common type of bacteria that can lead to pneumonia. This type of bacteria poses risks for young children but can also be risky for those who are older or have compromised immune systems.

The two vaccines are:

  • pneumococcal conjugate vaccine
  • pneumococcal polysaccharide vaccine

According to recent data, the CDC Advisory Committee on Immunization Practices recommend that people who are 65 and older should get the Pneumovax 23 shot.

However, both vaccines may be needed in certain circumstances when there is greater risk. These situations can include:

  • if you live in a nursing home or long-term care facility
  • if you live in an area with many unvaccinated children
  • if you travel to areas with a large population of unvaccinated children

Here is a comparison between the two available vaccines:

Protects against 13 strains of Streptococcus pneumoniae Protects against 23 strains of Streptococcus pneumoniae
No longer routinely given to people 65 and older One dose for anyone 65 years and older
Only given if you and your doctor decide it is needed to protect you from risk, then one dose for those 65 and older If you were already given PCV13, you should get PCV23 at least 1 year later

Pneumonia vaccines can prevent serious infections from the most common strains of pneumococcal bacteria.

Possible side effects

How Much Do Vaccines Cost

The cost for vaccines depends on which portion of Medicare is paying and what the vaccine is.

You wont pay anything for vaccines that Medicare Part B covers. But if you have Medicare Part C , you should check with your insurance plan.

You may need to get your vaccine from a plan-approved provider or pharmacy. If youre following the rules of your Medicare Advantage plan, you shouldnt have to pay anything for your vaccine.

If you get a vaccine that Part D covers, your Part D insurance company will negotiate a price that includes the vaccine costs and its administration. The costs include:

  • vaccine administration fee
  • vaccine ingredient costs

Your doctor will bill your Part D plan directly. You may be responsible for costs that include a copayment or coinsurance.

Sometimes, your plan may require you to pay your provider up front for the Medicare Part D vaccine, then submit a claim to your Part D plan for reimbursement. When this is the case, you may want to contact your plan before getting the vaccine just to confirm your coverage.

Who Should Get Pneumococcal Vaccines

CDC recommends pneumococcal vaccination for all children younger than 2 years old and all adults 65 years or older. In certain situations, older children and other adults should also get pneumococcal vaccines. Below is more information about who should and should not get each type of pneumococcal vaccine.

Talk to your or your childs doctor about what is best for your specific situation.

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Who Should Get A Pneumonia Shot

The Centers for Disease Control and Prevention recommends pneumonia vaccines for children younger than 2 years old and adults 65 years and older. Between the ages of 2 to 65 years, the pneumonia vaccine is only recommended for individuals that are at a higher risk due to certain medical conditions that lower their immune systems.

Pneumonia vaccines are best for high-risk groups such as people over the age of 65, smokers, and people with lung disease like COPD and asthma, says Amy Deviney, family nurse practitioner in Denver, CO. There are two vaccinations that should be given a year apart to protect from several different strains of pneumonia. Prevnar 13 given first and then Pneumovax 23 given a year later.

There are some individuals ages 65 years and older who should NOT get the vaccine according to the CDC:

  • Any individual who has had a life-threatening or severe allergic reaction to Prevnar 13, Pneumovax 23, an earlier pneumonia vaccine labeled PCV7 , or a vaccine with diphtheria toxoid .
  • Any individual who is not feeling well the day of the vaccine. You can reschedule your appointment for when you feel better.

Does Medicare Cover The Hepatitis B Vaccine

Have you got your flu shot yet? It

Medicare Part B and Medicare Advantage plans will cover injection of the Hepatitis B vaccine if you are considered at medium or high risk for Hepatitis B.

You may have an increased risk if:

  • You have hemophilia
  • You live with another person who has Hepatitis B
  • You work in health care and have frequent contact with blood and other bodily fluids

Your doctor can help you determine if youre at increased risk for contracting Hepatitis B.

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How Often Can I Get The Vaccine

Medicare will pay for your vaccination under your Part B coverage. You will be able to get two vaccinations: one at any time you choose, and another fully covered vaccination at least one year after the first.

If your doctor notes that you need another pneumococcal vaccination, you may need to pay some or all of the cost associated. If this is the case, make sure you understand how much you will have to pay beforehand, if possible.

You will only receive full coverage for your pneumococcal vaccination if your doctor accepts Medicare assignment. This means that they charge only the Medicare-approved amount for their services, which results in no excess charges. If youre unsure whether or not your doctor accepts Medicare assignment, they should be able to tell you.

What Parts Of Medicare Cover The Vaccine

Many vaccines are covered by Medicare Part D, which offers prescription drug coverage. However, Part D prescription drug coverage usually wont cover something thats already covered by Part B medical insurance. Pneumonia shots are covered by Part B, but remember that many other vaccinations are covered by Part D instead.

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How Much Does Medicare Pay For Pneumonia Vaccine

The good news is Medicare pays for the entire cost of pneumococcal preventive vaccines. Whether you have a Medicare Part B plan or a Medicare Advantage plan, both cover the full cost of the vaccines.

Keep in mind, Medicare will cover 100% of the cost as long as you visit a Medicare-approved healthcare provider that accepts assignment. This means the provider agrees to accept Medicare-approved reimbursement rates for the vaccines.

If you have a Medicare Advantage plan you may need to visit an in-network provider to get 100% of the cost covered.

Plan ahead before visiting a provider to make sure they accept assignment. You can call your provider directly, or check with your individual plan to find a covered provider near you.

Finding Vaccines For Children

Medicare & You: Flu Prevention

PCV13 is part of the routine childhood immunization schedule. Therefore, it is regularly available for children at:

  • Pediatric and family practice offices
  • Community health clinics
  • Health departments
  • Other community locations, such as schools and religious centers

You can also contact your state health department to learn more about where to get pneumococcal vaccines in your community.

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What Types Of The Vaccine Are There

Like some other vaccines out there, there is more than one type of pneumococcal vaccine. The main varieties are known as PCV13 and PPSV23. PCV13 stands for pneumococcal conjugate vaccine, while PPSV23 is stands for pneumococcal polysaccharide vaccine. The numbers reflect the number of bacterial strains that the vaccine protects against: 13 and 23 respectively

Usually, it is suggested that children under 2 receive the PCV13 vaccine, while seniors receive the PPSV23 vaccine. However, your doctor will let you know which vaccine you need to take, as some people with certain conditions have different needs. Medical advice should be received only from your doctor.

How Much Does Prevnar 13 Cost

As long as your provider is enrolled in Medicare, Part B will cover the complete cost of Prevnar 13, with no copay or coinsurance required. The Part B deductible doesnt apply to the pneumonia shot, so you shouldnt receive a bill or be asked to pay any portion of its cost up front.

If you have Part C, make sure to use an in-network provider. A list of these providers should be available on your plans website. If you dont use an in-network provider, you may get stuck with out-of-pocket costs for Prevnar 13.

vaccine. It protects against pneumococcal disease caused by Streptococcus pneumonia. This is a type of a bacteria that has more than 90 different strains.

Prevnar 13 protects against 13 Streptococcus strains.

In 2019, the CDCs Advisory Committee on Immunization Practices changed its recommendations for immunization with Prevnar 13 in people over age 65.

This change wasnt based on any problem with the vaccine, but rather on the success of its use in children. Because so many children are now routinely vaccinated with Prevnar 13, the prevalence of the bacterial strains it protects against has sharply declined in the United States.

However, Prevnar 13 is still recommended for certain people ages 65 and over, such as those who:

  • live with a cerebrospinal fluid leak
  • live in long-term care facilities, such as nursing homes
  • travel to areas where children are not routinely given Prevnar 13

You and your doctor may instead decide that you need only Pneumovax 23.

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Does Medicare Cover Prevnar 13

Most vaccines required for preventive care are covered under Medicare Part D. Part D is optional prescription drug coverage that you may purchase from a private insurance company.

The two pneumonia vaccines, Prevnar 13 and Pneumovax 23, are covered instead by Medicare Part B. Flu shots are also covered by Part B.

Part B covers preventive care and medically necessary services you receive as an outpatient. Together Medicare Part A and Part B make up what is known as original Medicare.

To get full coverage for Prevnar 13, or any vaccine, youll have to go to a Medicare-approved provider. This may be a doctor, pharmacist, or other Medicare-approved professional. You can look up and compare Medicare-approved doctors and hospitals here.

Like Part D, Medicare Part C plans are purchased from private insurance providers. Part C plans must cover at least as much as original Medicare does. If you have a Part C plan, itll cover Prevnar 13 as long as you receive it from an in-network provider.

Do I Have To Pay For Vaccines With Medicare

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You pay nothing for vaccines covered by Part B flu, pneumonia and Hepatitis B as long as your provider accepts Medicare.

Your cost for vaccines covered by Part D will depend on your specific plan. You may pay a copay or coinsurance, but it will depend on your plan and the provider.

The location where you get vaccinated may also affect your cost. For example, your costs may be lower if you get a vaccine at a pharmacy versus in a doctors office.

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Who Should Get The Vaccine

To answer this question, first and foremost you should speak to your doctor. There is no substitute for professional medical advice, so this information will just refer to who usually gets the vaccine.

The pneumococcal vaccine is usually given to very young children or seniors. This is because these populations are usually most susceptible to pneumococcal diseases. If you receive Medicare benefits, you should talk to your doctor about getting vaccinated as soon as you can.

What Vaccines Does Medicare Part B Cover

Medicare Part B generally covers vaccines for:

One flu shot per flu season. You pay generally nothing if the provider accepts assignment for giving the shot.

People at medium to high risk for Hepatitis B are covered. People at low risk may not be covered. You generally pay nothing if the provider accepts assignment for giving the shot.

  • Pneumococcal to prevent pneumonia

All people with Medicare Part B are covered. You generally pay nothing if your provider accepts assignment for giving the shot.

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Does Medicare Cover The Pneumonia Vaccine

Medicare Part B is likely to cover the pneumonia vaccine if your health care provider accepts the assignment. You are not required to make any contributions toward the cost of your vaccines.

If you’re eligible, Medicare coverage entitles you to the first shot and then a second shot at least a year later if it is a different vaccine. Having two different pneumonia vaccines can give you more comprehensive protection because it helps you develop immunity against more than one strain.

Your doctor may recommend getting a pneumonia shot more often than Medicare covers if you have certain health conditions. You are responsible for paying for any additional shots out of pocket.

Although some providers choose to offer additional benefits, Medicare Advantage Plans must provide the same benefits as Original Medicare. Therefore, you will be entitled to a pneumonia vaccine through your Medicare Advantage Plan if you had been eligible through Original Medicare.

Should Seniors Get Pneumonia Vaccine

Medicare Coverage and Payment of Virtual Services

Getting your pneumonia vaccine is important. According to the CDC, pneumonia causes more than 43,000 deaths each year in the US. Your immune system weakens with age and this can make you more vulnerable to infections like pneumonia.

Pneumococcal pneumonia is highly contagious and easily spread through air droplets from coughing, sneezing, or contact with surfaces with the bacteria. The PPSV23 vaccine is around 60% to 80% effective against severe pneumococcal disease in older adults. Even if youve had pneumonia in the past, you should still get vaccinated because there are many pneumococcal strains.

This is why CDC recommends everyone 65 years and older get vaccinated with the PPSV23 shot to prevent serious infection and complications.

Talk with your doctor to learn more about the benefits and risks of pneumococcal vaccines.

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Whats Included In Medicare Vaccine Coverage

Original Medicare covers several common vaccines, but you may need to meet certain eligibility requirements first. For instance:

  • Pneumococcal Vaccine: You can receive the first shot at any time, but inorder to receive a second one, you must get it within one year of the first.
  • HepatitisB Vaccine: Your doctor must determine that youre at a medium or higherrisk in order to receive the Hep B vaccine. Factors that may increase your riskinclude if you live with someone who has the virus, you have diabetes,hemophilia, or End-Stage Renal Disease, or if you work in a health careenvironment and regularly come in contact with bodily fluids.

You may be able to receive the vaccines covered under Original Medicare at your doctors office or at a nearby pharmacy. You should consult with your healthcare professional ahead of time to ensure that they accept Medicare, and that you meet any necessary eligibility guidelines. Youll typically be able to receive covered vaccines at no additional cost, as long as your healthcare provider accepts Medicares payment terms.

Vaccines Covered By Medicare Part D

Medicare Part D covers all commercially available vaccines needed to prevent illness. You can get Part D coverage through a stand-alone Medicare prescription drug plan or a Medicare Advantage plan that includes drug coverage.

Vaccines covered by Part D include the following:

  • Shingles vaccine: One-time vaccine given in two shots over two to six months
  • Tdap vaccine : One shot if youve never been vaccinated, and a booster every ten years
  • Other vaccines covered: Vaccines that are “reasonable and necessary” to prevent illness and are not covered by Part B

Part D may also cover vaccines you may need if you are traveling internationally. Talk with your doctor about your travel plans and ask what vaccines are recommended.

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Who Might Not Be Able To Get These Vaccines

Because of age or health conditions, some people should not get certain vaccines or should wait before getting them. Read the guidelines below specific to pneumococcal vaccines and ask your or your childs doctor for more information.

  • Children younger than 2 years old should not get PPSV23.
  • Anyone younger than 19 years old should not get PCV15 or PCV20.

In addition, tell the person who is giving you or your child a pneumococcal vaccine if:

You or your child have had an allergic reaction to an earlier pneumococcal shot or have any severe, life-threatening allergies.

  • Do not get a PCV shot if you have ever had a severe allergic reaction after
  • Any type of PCV
  • Any vaccine containing diphtheria toxoid
  • Do not get a PPSV23 shot if you have ever had a severe allergic reaction to that vaccine.
  • Anyone with a severe, life-threatening allergy to any part of these vaccines should not get that vaccine. Your or your childs doctor can tell you about the vaccines ingredients.
  • You or your child are not feeling well.

    • People who have a mild illness, such as a cold, can probably get vaccinated. People who have a more serious illness should probably wait until they recover. Your or your childs doctor can advise you.

    Medicare Covers A Variety Of Vaccinations At No Cost To You Including The Pneumonia Or Pneumococcal Vaccine

    How vaccines help improve our immune system?

    Medicare does cover the Pneumonia vaccine, but the exact conditions will vary. Usually, Medicare will provide full coverage for two doses of the vaccine, but the situation can be different if you have a Part C Medicare Advantage Plan. Well go through all of the details here, so you can know what to expect.

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