Medicare covers pneumonia shots, but the details depend on which vaccine, which part of Medicare you have, and your age

Medicare Part B covers two pneumonia vaccines at no cost to you: Pneumococcal Polysaccharide Vaccine (PPSV23) and Pneumococcal Conjugate Vaccine (PCV20 or PCV15). Part B pays for the full cost when you receive the shot at a Medicare-approved provider. You pay nothing out of pocket if your provider accepts Medicare assignment. If your provider does not accept assignment, you may owe up to 15 percent of the Medicare-approved amount, though this is rare for preventive vaccines.

The vaccine you need and when you need it depends on your age and health history. Medicare has specific rules about which shot to get first, how many doses you need, and how long to wait between doses. These rules changed in 2024, so if you received pneumonia shots years ago, the current recommendation may be different.

Part D (prescription drug coverage) does not cover pneumonia shots — Part B does. If you have only Part A, you will need to enroll in Part B or find a community health center that offers the vaccine on a sliding fee scale.

Key Takeaways

  • Medicare Part B covers both PCV20 (or PCV15) and PPSV23 pneumonia vaccines at no cost when given by a Medicare-approved provider.
  • The vaccine schedule depends on your age and whether you have certain health conditions, so ask your doctor which shot you need and when.
  • You should receive the vaccines at your doctor's office, a pharmacy, or a clinic — anywhere that accepts Medicare and administers vaccines.
  • If you have only Part A, you are not covered for pneumonia shots under Part B; you may need to enroll in Part B or seek care at a federally may have access to health center.
  • Bring your Medicare card when you go for the shot, and tell the provider you want to use Medicare to avoid unexpected bills.

Which pneumonia vaccines Medicare covers

Medicare Part B covers PCV20 (Pneumococcal Conjugate Vaccine 20-valent) and PCV15 (Pneumococcal Conjugate Vaccine 15-valent) as well as PPSV23 (Pneumococcal Polysaccharide Vaccine 23-valent). These are the only pneumonia vaccines Medicare pays for. Other pneumococcal vaccines exist but are not covered by Medicare.

PCV20 and PCV15 are newer vaccines that protect against more strains of pneumococcal bacteria than older vaccines. PPSV23 has been used for decades and protects against 23 strains. Most people now need both types — one from the PCV family and one PPSV23 — but the order and timing depend on your age and health.

Your doctor will tell you which vaccine to get based on current Medicare guidelines. Do not assume you know which one you need; guidelines change, and what was recommended five years ago may not be what Medicare recommends now.

Who gets covered and at what age

All Medicare beneficiaries age 65 and older are covered for pneumonia vaccines under Part B. You do not need to meet any other condition — age 65 is the threshold. If you are under 65 and have Medicare because of disability or end-stage renal disease, you are also covered.

People under 65 with certain chronic conditions — such as chronic lung disease, heart disease, diabetes, or a weakened immune system — may also be covered, but you need a doctor's order stating the medical reason. Medicare will not pay without documentation that the vaccine is medically necessary for your condition.

If you have already received pneumonia shots before age 65, tell your doctor. The number of doses you need now depends on what you received before, when you received it, and what type of vaccine it was. Mixing old and new vaccine schedules can be confusing, so bring any records you have.

How to get your pneumonia shot covered by Medicare

Schedule an appointment with your primary care doctor, a nurse practitioner, a physician assistant, or a pharmacist at a pharmacy that accepts Medicare. Most primary care offices, urgent care clinics, and pharmacy chains (CVS, Walgreens, Rite Aid) accept Medicare for vaccines. Call ahead and confirm they accept Medicare and that they have the specific vaccine your doctor recommends in stock.

Bring your Medicare card and your insurance information. Tell the provider you want to use Medicare to pay. If you have a supplemental insurance plan (Medigap) or Medicare Advantage, mention that too, though it usually does not change the cost for preventive vaccines.

The provider will document the vaccine in your medical record and report it to Medicare. You should receive a record card showing which vaccine you got and the date. Keep this card — you will need it to know when your next dose is due.

What you pay out of pocket

If your provider accepts Medicare assignment, you pay nothing. Medicare Part B covers the full cost of the vaccine and the administration fee. This is true even if you have not met your Part B deductible for the year — preventive vaccines are covered with no deductible.

If your provider does not accept Medicare assignment (which is uncommon for vaccines), you may owe up to 15 percent of the Medicare-approved amount. Before your appointment, ask the provider whether they accept Medicare assignment. If they do not, ask what the out-of-pocket cost will be.

If you have a Medicare Advantage plan instead of Original Medicare, your coverage is the same — pneumonia vaccines are covered with no cost to you. Your plan may require you to use in-network providers, so check your plan documents or call the plan to find a provider near you.

The current vaccine schedule for ages 65 and older

As of 2024, Medicare recommends that most people age 65 and older receive one dose of PCV20, or alternatively one dose of PCV15 followed by one dose of PPSV23 at least one year later. The exact schedule depends on whether you have received pneumonia vaccines before.

If you have never had a pneumonia vaccine, you need one dose of PCV20 (or PCV15 plus PPSV23 later). If you previously received PPSV23 but never a PCV vaccine, you need one dose of PCV20 or PCV15 at least one year after your PPSV23. If you previously received both types, you may not need another dose, but your doctor will confirm based on when you received them.

Do not try to figure out your own schedule. Bring any records of past pneumonia shots to your doctor's appointment, and let your doctor decide what you need now. The rules are complex, and getting the order wrong means you may not be fully protected.

If you have Part A only, or no Medicare enrollment

Part A does not cover pneumonia vaccines. If you have only Part A and no Part B, you are not covered for the vaccine under Medicare. You have two options: enroll in Part B during the next enrollment period, or find a community health center or public health clinic that offers pneumonia shots on a sliding fee scale based on income.

To find a sliding-scale clinic, call 211 (a referral service) or search the Health Resources and Services Administration (HRSA) website for "Federally may have access to Health Centers" in your area. These clinics serve uninsured and underinsured people and can often provide pneumonia vaccines at a reduced cost.

If you are not yet enrolled in Medicare, you can enroll in Part B during the General Enrollment Period (January 1 to March 31 each year), with coverage starting July 1. If you delayed Part B and are now over 65, you may owe a late enrollment penalty, but it is still worth enrolling to cover vaccines and other preventive care going forward.

Common mistakes to avoid

Do not assume you have already had all the pneumonia vaccines you need. Recommendations change, and older vaccines may not protect against all strains covered by newer ones. Ask your doctor at your next visit whether you are up to date.

Do not go to a provider who does not accept Medicare without asking the cost first. Some urgent care clinics and retail clinics do not accept Medicare, and you could end up paying the full price out of pocket. Always confirm before your appointment.

Do not wait to get the vaccine until you are sick. Pneumonia vaccines work best when you are healthy. If you are currently ill or have a fever, reschedule for when you feel better.

Do not forget to bring your Medicare card. Without it, the provider may not be able to bill Medicare, and you could be charged. If you lost your card, call Medicare at 1-800-MEDICARE to request a replacement before your appointment.

Frequently Asked Questions

Do I need both PCV20 and PPSV23, or just one?

Most people age 65 and older need both types of pneumococcal protection, but you may receive it as one dose of PCV20 alone, or as PCV15 followed by PPSV23. Your doctor will decide based on your age, health history, and any vaccines you have had before. One dose of PCV20 is often the simplest option.

Will my Medicare Advantage plan cover pneumonia shots?

Yes. All Medicare Advantage plans must cover the same preventive vaccines that Original Medicare covers, including pneumonia shots, at no cost to you. You may need to use an in-network provider, so check your plan or call the plan's customer service to find a location near you.

What if I got a pneumonia shot before I turned 65?

Tell your doctor when you received it and what type of vaccine it was. Your current vaccine needs depend on your age now, what you received before, and how long ago you received it. Bring any records or vaccination cards you have to your appointment so your doctor can plan the right schedule.

Can I get the pneumonia shot at a pharmacy instead of my doctor's office?

Yes. Pharmacies at CVS, Walgreens, Rite Aid, and other chains accept Medicare for pneumonia vaccines. Call ahead to confirm they have the vaccine your doctor recommends and that they accept Medicare. You will still need your Medicare card and your doctor's order if one is required.

Do I have to pay my Part B deductible before the pneumonia shot is covered?

No. Preventive vaccines, including pneumonia shots, are covered by Medicare Part B with no deductible. You pay nothing even if you have not met your yearly deductible for other services.