Does Medicare Cover Pneumonia Shots?

Pneumonia is a common infection involving one or both lungs. Inflammation, pus, and fluid can build-up in the lungs, making it hard to breathe. According to the Centers for Disease Control and Prevention (CDC), 1.3 million people visit emergency room each year due to pneumonia.

Pneumococcal vaccines can prevent common bacterial infections from Streptococcus pneumoniae. There are two types of pneumonia vaccines available to prevent specific strains of this bacteria.

Fortunately, if you have Medicare Part B or Part C, you will be covered for both kinds of pneumococcal vaccines.

Let’s take a closer look at pneumonia vaccines and how Medicare covers them.

Medicare coverage for the pneumonia vaccine

Most preventive vaccines are covered under Part D, the prescription drug part of Medicare. Medicare Part B covers a few specific vaccines, like the two pneumonia vaccines. Medicare Advantage plans, sometimes called Part C, also cover the pneumonia vaccines, along with other vaccines you may need.

If you are enrolled in original Medicare (Part A and Part B), or a Part C plan, you are automatically eligible for the pneumonia vaccines. Since there are two types of vaccines for pneumonia, you and your doctor will decide if you need one or both vaccines. We’ll get into the details of the two different types a little later.

Part B coverage

Medicare Part B covers the following types of vaccines:

  • influenza vaccine (flu)
  • hepatitis B vaccine (for those at high risk)
  • pneumococcal vaccines (PCV13 and PPSV23 for bacterial Streptococcus pneumoniae)
  • tetanus shot (treatment after exposure)
  • rabies shot (treatment after exposure)

Part B typically pays 80% of covered costs if you visit Medicare-approved providers. However, there are no out-of-pocket costs for vaccines covered by Part B. That means, you’ll pay $0 for the vaccine, as long as the provider accepts Medicare assignment.

Providers who accept assignment agree to Medicare-approved rates, which are usually lower than standard prices. Vaccine providers can be doctors or pharmacists. You can find a Medicare-approved provider here.

Part C coverage

Medicare Part C, or Medicare Advantage plans, are private insurance plans that offer many of the same benefits as original Medicare parts A and B along with some extra options. By law, Medicare Advantage plans are required to offer at least the same amount of coverage as original Medicare, so you will also pay $0 for the pneumonia vaccines through these plans.

Medicare Advantage plans typically have limitations that require you to use service providers that are in the plan’s network. Check your plan’s list of in- network providers before making an appointment to be vaccinated to ensure all costs will be covered.

How much do the pneumonia vaccines cost?

Medicare Part B covers 100% of the cost of the pneumococcal vaccines with no copayments or other costs. Check that your provider accepts Medicare assignment before the visit to ensure full coverage.

The costs for a Part B plan in 2020 include a monthly premium of $144.60 and a deductible of $198.

There are many different Medicare Advantage plans offered by private insurance companies. Each come with different costs. Review the benefits and costs of each plan with your specific budget and needs in mind to make the best choice for your situation.

What is the pneumonia vaccine?

There are currently two types of pneumococcal vaccines that cover different strains of a common type of bacteria (Streptococcus pneumoniae) 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 (PCV13 or Prevnar 13)
  • pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax 23)

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:

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

According to the CDC, in adults 65 and older, the PCV13 vaccine has a 75% effectiveness rate and the PPSV23 vaccine has an effectiveness rate of 50% to 85% in terms of protecting individuals against pneumococcal disease.

Discuss your risks with your doctor to decide if you need both PCV13 and PPSV23 or if one shot is enough. Part B will cover both shots if required and given at least 1 year apart. For most people, one PPSV23 shot is enough.

Side effects of pneumococcal vaccines are generally mild. They include:

  • pain at the injection site
  • inflammation
  • fever
  • headache

What is pneumonia?

Pneumococcal infections caused by Streptococcus pneumoniae can be mild and common like ear infections or sinus infections. However, when the infection spreads to other parts of the body, it can be serious and cause pneumonia, meningitis, and bacteremia (bacteria in the bloodstream).

Some people are at higher risk of pneumonia infections. They include children under 2 years of age, adults 65 and older, those with weakened immune systems, and those with other chronic health conditions such as diabetes, COPD, or asthma.

Pneumonia can be easily spread by sneezing, coughing, touching an infected surface, and from being in areas with high infection rates like hospitals. According to the CDC, around 1 in 20 older adults die from pneumococcal pneumonia (lung infection) if they get it.

Along with the vaccines, you can increase prevention efforts by washing hands frequently, eating healthy foods, and reducing exposure to people who are sick when possible.

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