Medicare covers pneumonia shots at no cost to you

Yes, Medicare Part B covers pneumococcal vaccines (the shots that protect against pneumonia caused by pneumococcal bacteria) with no copay or coinsurance when you receive them from an in-network provider. You pay nothing out of pocket for the vaccine itself. The specific shots covered and when you can receive them depend on your age and vaccination history.

Medicare has updated its pneumococcal vaccine recommendations several times in recent years. The current guidance covers two main vaccines: pneumococcal conjugate vaccines (PCV) and pneumococcal polysaccharide vaccines (PPSV23). Which ones you need, and in what order, depends on whether you have already been vaccinated and when.

Key Takeaways

  • Medicare Part B covers pneumococcal vaccines at no cost when administered by an in-network provider, with no copay or deductible.
  • Adults age 65 and older who have never received a pneumococcal vaccine should start with a PCV20 shot, or PCV15 followed by PPSV23 if PCV20 is unavailable.
  • If you received PPSV23 before age 65, you may be due for additional doses after turning 65, depending on how long ago you were vaccinated.
  • You can receive your pneumococcal vaccine at your doctor's office, a pharmacy, or a health clinic — any location that accepts Medicare.
  • Talk to your doctor about your vaccination history so they can determine which shots you need and when.

What pneumococcal vaccines Medicare covers

Medicare covers two types of pneumococcal vaccines. PCV20 (Pneumovax 20) is a single-dose conjugate vaccine that protects against 20 strains of pneumococcal bacteria. PCV15 (Prevnar 15) is another conjugate vaccine covering 15 strains. PPSV23 (Pneumovax 23) is a polysaccharide vaccine covering 23 strains and is often given after a conjugate vaccine.

The difference between these vaccines matters for your protection. Conjugate vaccines (PCV20 and PCV15) work better in older adults and people with weakened immune systems. Polysaccharide vaccines (PPSV23) cover additional strains but work less effectively on their own in older people. That is why current guidance often recommends a conjugate vaccine first, followed by PPSV23 if needed.

Medicare covers all three vaccines with no cost to you when given by an in-network provider. Your doctor will recommend which vaccine or sequence makes sense based on your age and what you have already received.

Who should get pneumococcal vaccines under Medicare

All adults age 65 and older should have pneumococcal protection. If you have never received a pneumococcal vaccine, you should receive one now. If you received PPSV23 before you turned 65, you may need additional doses after age 65, depending on how many years have passed and whether you have certain medical conditions.

Adults under 65 with chronic lung disease, heart disease, diabetes, or a weakened immune system should also have pneumococcal vaccines. If you have one of these conditions and are covered by Medicare (for example, through disability), talk to your doctor about which vaccines you need.

The timing between doses matters. If your doctor recommends both a conjugate vaccine and PPSV23, there is usually a waiting period between them — typically at least one year. Your doctor will schedule these appropriately and track what you have received.

How to get your pneumococcal vaccine through Medicare

You can receive your pneumococcal vaccine at your primary care doctor's office, an urgent care clinic, a pharmacy, or a health department clinic — anywhere that accepts Medicare. Call ahead to confirm they have the vaccine in stock and that they accept your specific Medicare plan.

Bring your Medicare card when you go. Tell the provider about any pneumococcal vaccines you have already received and when you received them. If you do not remember, ask your doctor's office to check your medical records, or call your previous providers. This information helps your current provider choose the right vaccine and timing.

You do not need a referral from your primary care doctor to receive a vaccine at a pharmacy or clinic, though your doctor can help coordinate your vaccination schedule if you prefer. Many people find it convenient to get their pneumococcal vaccine during a routine visit or at the same time as their annual flu shot.

What happens if you received PPSV23 before age 65

If you received PPSV23 (the older polysaccharide vaccine) before turning 65, your protection may not be as strong as it could be with newer guidance. Medicare now covers additional doses or a different vaccine sequence after age 65, depending on when you last received PPSV23.

The timing depends on your specific situation. If you received PPSV23 five or more years ago, you may be due for a conjugate vaccine (PCV20 or PCV15) now. If you received it more recently, your doctor may recommend waiting a certain period before your next dose. Your doctor can review your vaccination record and tell you what comes next.

This is another reason to mention your vaccination history when you see your doctor. If your previous provider did not document the vaccine in your current medical record, ask for those records to be transferred or request a copy of your vaccination card.

Medicare Part B versus Part D coverage

Pneumococcal vaccines are covered under Medicare Part B, which means they are covered as a preventive service with no cost to you. This is different from prescription drug coverage (Part D). You do not need to use your Part D prescription drug plan to get a pneumococcal vaccine.

Because Part B covers the vaccine, you pay nothing for the shot itself — no copay, no coinsurance, and no deductible. If you receive the vaccine at a doctor's office, you may owe a separate office visit copay if you are seeing the doctor for other reasons, but the vaccine itself is free.

If you receive the vaccine at a pharmacy or clinic, there is typically no office visit charge at all. Many pharmacies offer pneumococcal vaccines as a walk-in service covered entirely by Medicare Part B.

What to do if your provider says the vaccine is not covered

If a provider tells you that Medicare will not cover your pneumococcal vaccine, ask them to verify your coverage. Occasionally, a provider's billing system is out of date or there is confusion about which vaccine is being given. Asking them to double-check can resolve the issue.

If the provider still says it is not covered, you have options. You can contact Medicare directly at 1-800-MEDICARE to confirm what is covered under your plan. You can also ask your doctor to submit a coverage information request, which Medicare will review.

In the rare case that a provider will not give you the vaccine because of a billing dispute, you can seek the vaccine elsewhere — at another doctor's office, a pharmacy, or a health department clinic. Do not let a billing question prevent you from getting protected.

Frequently Asked Questions

Can I get my pneumococcal vaccine at a pharmacy instead of my doctor's office?

Yes. Pharmacies that accept Medicare can administer pneumococcal vaccines covered by Part B at no cost to you. Many people find it convenient to get their vaccine at a pharmacy without scheduling a separate doctor's appointment. Call ahead to confirm the pharmacy has the vaccine in stock.

How long do pneumococcal vaccines last?

Pneumococcal vaccines do not have a fixed expiration date. Protection lasts for years, but your doctor may recommend a booster dose depending on your age, medical history, and which vaccine you received. Your doctor will tell you if and when you need another dose.

What if I have a severe allergy to vaccine ingredients?

Tell your doctor or pharmacist about any allergies before receiving the vaccine. They can review the vaccine ingredients and determine whether it is safe for you. In rare cases, a person cannot receive a particular vaccine, but your provider can discuss alternatives or timing options.

Do I need a pneumococcal vaccine if I already had pneumonia?

Yes. Having pneumonia in the past does not mean you are protected against all types of pneumococcal pneumonia. The vaccine protects against specific bacterial strains. Talk to your doctor about when to receive your vaccine — they may recommend waiting a certain period after a recent illness.

Will Medicare cover pneumococcal vaccines if I am still working and have employer health insurance?

If you have both Medicare and employer coverage, Medicare is usually the primary payer for preventive vaccines. Your employer plan may also cover the vaccine. Either way, you should have coverage at no cost. Show both insurance cards when you receive the vaccine.