Medicare covers Prevnar 20, but the details depend on which part of Medicare you have

Prevnar 20 is a pneumococcal vaccine that protects against 20 strains of pneumococcal bacteria. Medicare Part B covers it for people 60 and older, and Part D (prescription drug plans) may also cover it depending on your specific plan. However, you may still owe a copay or coinsurance, and coverage rules changed in 2024 to expand who qualifies.

The vaccine is given as a single shot and is recommended for most seniors, especially those with certain health conditions or risk factors. Your doctor can tell you whether you need it based on your age, health history, and any previous pneumococcal vaccines you have received.

Key Takeaways

  • Medicare Part B covers Prevnar 20 for people 60 and older without a copay or coinsurance when given by an in-network provider.
  • If you receive the vaccine at a pharmacy instead of a doctor's office, your Part D prescription drug plan may cover it, and you may owe a copay depending on your plan's formulary.
  • You may be able to receive Prevnar 20 even if you had older pneumococcal vaccines in the past, because CDC recommendations changed in 2024.
  • Your doctor or pharmacist can check your vaccination records to see whether you need Prevnar 20 and which Medicare benefit covers it in your situation.

How Medicare Part B covers Prevnar 20

Medicare Part B covers Prevnar 20 as a preventive vaccine with no copay or coinsurance when you receive it from a doctor, clinic, or hospital that accepts Medicare. This means you pay nothing out of pocket for the vaccine itself. You do not need to meet your deductible first.

The vaccine must be given by a provider enrolled in Medicare. If you go to an out-of-network provider, you may owe the full cost and then file a claim to Medicare yourself. Before your appointment, ask the office whether they accept Medicare and whether they have Prevnar 20 in stock, since some offices order it after you schedule.

Part B also covers the office visit during which you receive the vaccine, though you may owe a copay for the visit itself if it is a standard appointment rather than a preventive visit. Ask your doctor's office whether the visit will be billed as preventive (which has no copay) or as a regular office visit.

How Medicare Part D covers Prevnar 20 at pharmacies

If you receive Prevnar 20 at a pharmacy — such as at a retail pharmacy's vaccination clinic — your Medicare Part D prescription drug plan may cover it instead of Part B. Part D coverage varies by plan, and not all plans cover Prevnar 20 in the same way.

Some Part D plans include Prevnar 20 on their formulary (the list of covered drugs), while others do not. If your plan covers it, you will owe whatever copay your plan sets for vaccines, which is often $0 to $50. If your plan does not cover it, you may owe the full pharmacy price, which is typically $200 to $300.

Before you go to a pharmacy for the vaccine, call your Part D plan to ask whether Prevnar 20 is covered and what your copay will be. You can find your plan's customer service number on your insurance card or at Medicare.gov. The pharmacy can also check your coverage while you are there, but calling ahead saves time.

What changed in 2024 and who now qualifies

In June 2024, the CDC updated its pneumococcal vaccine recommendations. The new guidance means more seniors may now be recommended to receive Prevnar 20, even if they received older pneumococcal vaccines (such as Pneumovax 23) in the past.

The updated recommendations say that adults 60 and older should receive Prevnar 20. Adults 19 to 59 with certain chronic conditions — such as heart disease, diabetes, chronic lung disease, or a weakened immune system — may also be recommended to receive it. Your doctor can review your health history and tell you whether Prevnar 20 is right for you.

If you already received Pneumovax 23 or other older pneumococcal vaccines, you may still be able to receive Prevnar 20. The timing depends on which vaccine you had and when you had it. Your doctor or pharmacist can check your records and tell you when you can safely receive Prevnar 20.

What to do if your pharmacy says it is not covered

If a pharmacy tells you that Prevnar 20 is not covered by your Part D plan, you have options. First, ask the pharmacy to check whether it is covered under your Part B benefit instead. Many pharmacies can bill Medicare Part B directly, and you would owe nothing.

If the pharmacy cannot bill Part B, you can go to your doctor's office or a clinic to receive the vaccine there. Part B will cover it with no copay. This is often the simpler route if your doctor's office has the vaccine available.

If you want to pay out of pocket at the pharmacy rather than wait for a doctor's appointment, you can do that too. Ask the pharmacy for the cash price before you decide. Some pharmacies offer discounts or coupons that can lower the cost.

Questions to ask your doctor or pharmacist

Before you receive Prevnar 20, write down these questions to ask your doctor or pharmacist. Having this information ahead of time helps you understand your coverage and avoid surprises at the appointment.

  • Do I need Prevnar 20 based on my age and health history?
  • Have I already received any pneumococcal vaccines, and if so, when?
  • Will you bill Medicare Part B, or should I check my Part D plan?
  • Do you have Prevnar 20 in stock, or do I need to wait for you to order it?
  • Will I owe any copay or coinsurance?
  • If I had Pneumovax 23 before, how long should I wait before receiving Prevnar 20?

Frequently Asked Questions

Do I have to pay anything for Prevnar 20 under Medicare Part B?

No. Medicare Part B covers the vaccine with no copay or coinsurance when you receive it from an in-network provider. You do not pay for the vaccine itself. You may owe a copay for the office visit if it is billed as a regular appointment rather than a preventive visit, so ask your doctor's office beforehand.

Can I get Prevnar 20 if I already had Pneumovax 23?

Yes. The CDC updated its recommendations in 2024 to say that adults who previously received Pneumovax 23 may now receive Prevnar 20. The timing depends on when you had Pneumovax 23. Your doctor can review your vaccination records and tell you when it is safe to receive Prevnar 20.

What if my Part D plan does not cover Prevnar 20?

You can receive it under Medicare Part B instead by going to your doctor's office or a clinic. Part B covers it with no copay. Alternatively, you can pay the pharmacy's cash price out of pocket. Ask the pharmacy what they charge before you decide.

Will I need more than one dose of Prevnar 20?

Most people need only one dose of Prevnar 20. Your doctor will review your vaccination history to confirm. If you have a weakened immune system or certain other conditions, your doctor may recommend additional doses, but this is not common.

Where can I get Prevnar 20 — at my doctor's office or a pharmacy?

You can receive it at either location. Your doctor's office or clinic will bill Medicare Part B. A pharmacy's vaccination clinic may bill Part D instead. Call ahead to both locations to ask whether they have the vaccine in stock and what your out-of-pocket cost will be.