Medicare covers pneumococcal vaccines at no cost to you

Yes, Medicare Part B covers pneumococcal vaccines with no copay, coinsurance, or deductible when you receive them from an in-network provider. You do not pay anything out of pocket. Medicare covers two types of pneumococcal vaccines: Pneumococcal Conjugate Vaccine (PCV) and Pneumococcal Polysaccharide Vaccine (PPSV23). Which vaccines you need depends on your age and health history, and your doctor will recommend the right schedule for you.

The vaccines protect against infections caused by pneumococcal bacteria, which can lead to pneumonia, meningitis, and bloodstream infections. Older adults and people with certain chronic conditions are at higher risk for serious pneumococcal disease, which is why Medicare covers these vaccines as a preventive service.

Key Takeaways

  • Medicare Part B covers both PCV and PPSV23 pneumococcal vaccines at no cost when given by an in-network provider.
  • The vaccines you need depend on your age and whether you have chronic conditions like heart disease, diabetes, or lung disease.
  • Your doctor will tell you which vaccine to get and when, based on current CDC recommendations.
  • You should ask your doctor about pneumococcal vaccination at your next visit if you have not had these vaccines recently.

What the two pneumococcal vaccines do

PCV (Pneumococcal Conjugate Vaccine) protects against 20 strains of pneumococcal bacteria. It is newer than PPSV23 and works well in older adults. PPSV23 (Pneumococcal Polysaccharide Vaccine) protects against 23 strains. Many people need both vaccines over time because they protect against different strains and work together to give broader protection.

The CDC recommends that all adults 65 and older receive at least one dose of PCV. If you are 65 or older and have never had pneumococcal vaccines, your doctor will likely recommend PCV first, followed by PPSV23 at least one year later. If you already had PPSV23 before age 65, you may still need PCV when you turn 65.

People under 65 with chronic conditions like chronic heart disease, chronic lung disease, diabetes, or a weakened immune system may also need these vaccines. Your doctor will review your health history and tell you which vaccines are right for you.

How to get your pneumococcal vaccine through Medicare

Call your doctor's office and ask whether they have pneumococcal vaccines in stock and when you can come in. Many primary care offices give these vaccines during a regular visit. You can also get pneumococcal vaccines at some pharmacies that accept Medicare, such as CVS, Walgreens, and Rite Aid, though you should call ahead to confirm they have the specific vaccine your doctor recommended.

Bring your Medicare card with you. Tell the provider that you want the vaccine covered under Medicare Part B preventive services. If you use a Medicare Advantage plan (Part C), the vaccine is still covered at no cost, but you should check your plan's provider network to make sure the location you choose is in-network.

Keep a record of which vaccine you received and when. This helps your doctor track which vaccines you still need. If you do not remember what pneumococcal vaccines you have had, ask your doctor to check your medical records.

What happens if you go to an out-of-network provider

If you receive a pneumococcal vaccine from a provider who does not accept Medicare, you may have to pay the full cost upfront and then submit a claim to Medicare for reimbursement. The reimbursement may not cover the full amount the provider charged. To avoid this, always confirm that your provider accepts Medicare before you go in.

If you have a Medicare Advantage plan, using an out-of-network provider may result in higher costs or no coverage at all, depending on your plan. Check your plan documents or call your plan's customer service number before scheduling your vaccine.

When to get pneumococcal vaccines

If you are 65 or older and have never had a pneumococcal vaccine, talk to your doctor about getting one now. You do not have to wait for a specific time of year. You can get the vaccine at any time, though some people prefer to get it in the fall along with their flu shot.

If you had PPSV23 before you turned 65, you may need PCV at age 65 or later, depending on how long ago you had PPSV23. The timing matters because the vaccines work better when given in the right order. Your doctor will tell you the right schedule based on your vaccination history.

If you have a chronic condition that puts you at risk for pneumococcal disease, ask your doctor whether you need pneumococcal vaccines even if you are under 65. People with heart disease, lung disease, diabetes, or a weakened immune system may benefit from these vaccines at a younger age.

Side effects and what to expect

Most people have no side effects or only mild ones. Common side effects include soreness, redness, or swelling at the injection site, mild fever, or muscle aches. These usually go away within a day or two. Serious side effects are rare.

You can take over-the-counter pain reliever like acetaminophen or ibuprofen if you have soreness or fever after the vaccine. Drink plenty of water and rest if you feel tired. If you have severe allergic reaction symptoms such as difficulty breathing, swelling of the face or throat, or chest pain, call 911 or go to the emergency room right away.

Questions to ask your doctor

Before you get a pneumococcal vaccine, ask your doctor these questions: Have I had pneumococcal vaccines before, and if so, which ones and when? Which vaccine do I need now? When should I get my next pneumococcal vaccine? Do I have any health conditions that make pneumococcal vaccination especially important for me? Are there any reasons I should not get this vaccine right now?

If your doctor recommends two vaccines, ask the order in which you should get them and how long you should wait between them. Write down the name of the vaccine you receive and the date so you have a record for future visits.

Frequently Asked Questions

Do I need both PCV and PPSV23?

Many people 65 and older benefit from both vaccines because they protect against different strains of pneumococcal bacteria. Your doctor will look at your age, health history, and any previous pneumococcal vaccines you have had to decide whether you need both and in what order. The CDC recommendations have changed in recent years, so even if you had PPSV23 years ago, you may now need PCV.

Can I get pneumococcal vaccine at the same time as other vaccines?

Yes, you can get pneumococcal vaccine at the same visit as your flu shot, COVID-19 vaccine, or other vaccines. They can be given in different arms. Your doctor or nurse will tell you if there are any reasons to space out your vaccines.

What if I had pneumococcal vaccine years ago but do not remember which one?

Ask your doctor to check your medical records or vaccination history. Medicare and most doctor's offices keep records of vaccines you have received. Once your doctor knows which vaccines you have had and when, they can tell you whether you need additional pneumococcal vaccines now.

Does Medicare Advantage cover pneumococcal vaccines?

Yes, Medicare Advantage plans must cover the same preventive vaccines that Original Medicare covers, including pneumococcal vaccines at no cost. However, you must use an in-network provider. Check your plan's provider directory or call your plan to confirm that your doctor or pharmacy is in-network before you schedule your vaccine.

What if I am allergic to eggs or other ingredients?

Tell your doctor about any allergies before you get the vaccine. Pneumococcal vaccines do not contain eggs, but they may contain other ingredients you are allergic to. Your doctor can review the vaccine ingredients with you and decide whether the vaccine is safe for you or whether you should wait.