Medicare covers pneumonia shots, but which ones and how much you pay depends on your coverage type and age

Medicare Part B covers two pneumonia vaccines: Pneumococcal Polysaccharide Vaccine (PPSV23) and Pneumococcal Conjugate Vaccine (PCV20 or PCV15). If you have Original Medicare, you pay nothing for these vaccines — Part B covers them at 100 percent after you meet your Part B deductible. If you have a Medicare Advantage plan, your out-of-pocket cost varies by plan, but most cover pneumonia shots with little or no cost.

The vaccine you receive and when you receive it depends on your age and health history. Medicare's recommendations have changed in recent years, so even if you had a pneumonia shot years ago, you may be due for another one. Your doctor can tell you which vaccine is right for you based on your age and medical history.

Key Takeaways

  • Original Medicare Part B covers pneumonia vaccines at no cost to you after you meet your annual deductible.
  • Medicare Advantage plans cover pneumonia shots, though your copay or coinsurance varies by plan.
  • The specific pneumonia vaccine you need depends on your age and whether you have certain chronic conditions or risk factors.
  • You can receive pneumonia vaccines at your doctor's office, a pharmacy, or a health clinic that accepts Medicare.

How Original Medicare Covers Pneumonia Shots

If you have Original Medicare (Part A and Part B), Part B pays for pneumonia vaccines with no copay or coinsurance once you have met your Part B deductible for the year. The deductible amount changes each year — you can find the current year's deductible on Medicare.gov or by calling 1-800-MEDICARE.

After you meet your deductible, you pay nothing for the vaccine itself. However, you may be charged a small administration fee if you receive the shot at a doctor's office rather than a pharmacy, though many offices waive this fee for Medicare patients. If you receive the vaccine at a pharmacy, the administration fee is typically covered as well.

How Medicare Advantage Plans Cover Pneumonia Shots

Medicare Advantage plans (Part C) are required by federal law to cover the same pneumonia vaccines that Original Medicare covers. However, your out-of-pocket cost depends on your specific plan. Some plans cover pneumonia shots with no copay, while others charge a small copay — usually between $0 and $50.

Check your plan's formulary or call the plan directly to find out what you will pay. You can also ask your doctor's office to contact your plan before your appointment. Many Medicare Advantage plans partner with specific pharmacies or clinics, so you may save money by getting your shot at a network location.

Which Pneumonia Vaccines Medicare Covers

PCV20 is a newer vaccine that protects against 20 strains of pneumococcal bacteria. Medicare covers PCV20 for adults age 65 and older, and for younger adults with certain chronic conditions or weakened immune systems. PCV15 is an older vaccine that protects against 15 strains and may be used in some situations.

PPSV23 protects against 23 strains of pneumococcal bacteria. Medicare covers PPSV23 for all adults age 65 and older. If you received PPSV23 before age 65 because of a chronic condition, you may be due for another dose at age 65 or later, depending on how long ago you received the first shot.

Your doctor will recommend which vaccine you need based on your age, vaccination history, and any chronic conditions you have. You do not need to choose — your doctor will order the right vaccine for your situation.

Where to Get Your Pneumonia Shot

You can receive a pneumonia vaccine at your primary care doctor's office, a walk-in clinic, or a pharmacy. Most pharmacies that accept Medicare — including CVS, Walgreens, and Rite Aid — offer pneumonia shots. Some community health centers also provide them.

Call ahead to confirm that the location accepts your type of Medicare coverage and has the vaccine your doctor recommended in stock. If you use a Medicare Advantage plan, ask whether the location is in your plan's network to avoid higher out-of-pocket costs.

What Happens If You Delay Getting Your Shot

Pneumonia can be serious for older adults, especially those with chronic conditions like heart disease, diabetes, or lung disease. Medicare covers pneumonia vaccines because preventing the disease is far less costly and risky than treating it after infection occurs.

If you have not had a pneumonia shot or are unsure whether you are up to date, talk to your doctor at your next appointment. Your doctor's office can check your vaccination record and tell you whether you need a shot. There is no penalty for waiting, but the sooner you get vaccinated, the sooner you have protection.

Frequently Asked Questions

Do I need both PCV20 and PPSV23?

Not necessarily. Your doctor will recommend the right vaccine or vaccine sequence based on your age and health history. Some people need both vaccines given at different times, while others need only one. Your doctor will explain what is right for you.

Can I get a pneumonia shot at the same time as other vaccines?

Yes. You can receive a pneumonia vaccine at the same visit as a flu shot, shingles vaccine, or other vaccines. Getting multiple vaccines at once does not reduce how well any of them work. Your doctor or pharmacist will let you know if there are any spacing requirements between specific vaccines.

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

You may still be covered for another pneumonia vaccine at age 65 or later, depending on which vaccine you received and how long ago. Call your doctor or Medicare to find out whether you need an updated shot. Bring records of any pneumonia vaccines you have had in the past.

Will my Medicare Advantage plan charge me more if I go out of network?

Possibly. If you get your pneumonia shot at a pharmacy or clinic outside your plan's network, you may pay more than you would in-network. Call your plan before your appointment to find out which locations are in-network and what you will pay.

Is there a cost if my doctor's office gives me the shot?

After you meet your Part B deductible, Original Medicare covers the vaccine at no cost. Your doctor's office may charge an administration fee, but many waive it for Medicare patients. Ask when you schedule your appointment.