What Medicare covers for pneumonia shots
Medicare Part B covers pneumonia shots (pneumococcal vaccines) at no cost to you when you get them at a pharmacy, doctor's office, or hospital outpatient clinic. You pay nothing out of pocket — no copay, no coinsurance — as long as the pharmacy is in the Medicare network and the shot is given by a licensed pharmacist or other may have access to provider.
The coverage applies to two main pneumonia vaccines: Pneumovax 23 (PPSV23) and Prevnar 20 (PCV20). Medicare also covers Prevnar 15 (PCV15) in certain situations. Which vaccine you need depends on your age and health history, and your doctor can tell you which one is right for you.
This coverage is part of Medicare Part B's preventive services benefit. You do not need to meet your deductible first, and the shot does not count toward your deductible or out-of-pocket maximum.
Key Takeaways
- Medicare Part B pays the full cost of pneumonia shots at network pharmacies with no copay or deductible required.
- The pharmacy must be in the Medicare network and the shot must be given by a licensed pharmacist or may have access to provider for coverage to explore.
- You may need one or more pneumonia shots depending on your age and whether you have certain chronic conditions or risk factors.
- You can call your pharmacy ahead of time to confirm they accept Medicare and have the vaccine in stock before you go in.
Which pharmacies accept Medicare for pneumonia shots
Most major pharmacy chains accept Medicare Part B for pneumonia shots, including CVS, Walgreens, Rite Aid, and many independent pharmacies. However, not every location of a chain pharmacy is in the Medicare network, and coverage can vary by region.
Before you go to a pharmacy, call ahead and ask: "Do you accept Medicare Part B for pneumonia shots?" and "Do you have the pneumonia vaccine in stock?" This takes two minutes and saves you a wasted trip. You can also search for in-network pharmacies on Medicare.gov by entering your zip code.
If your regular pharmacy is not in the Medicare network, you can get the shot at any network pharmacy instead. Your insurance card will work the same way — just bring it with you.
What to bring and how the visit works
Bring your Medicare card and any other insurance cards you have. The pharmacist will ask about your medical history, including whether you have had pneumonia shots before and when. Be honest about this, because getting the wrong vaccine or the wrong number of doses can happen if the pharmacist does not have accurate information.
The pharmacist will also ask about allergies, especially to eggs or any ingredient in the vaccine. Tell them about any severe allergies you have had to vaccines in the past. This conversation usually takes 5 to 10 minutes.
After the shot, you will sit in the pharmacy for 15 minutes so staff can watch for any when ready reaction. Most people have no side effects or only mild arm soreness. You can leave after the 15-minute observation period.
How many pneumonia shots you might need
The number of pneumonia shots you need depends on your age and health. If you are 65 or older and have never had a pneumonia shot, you may need one or two shots depending on which vaccine your doctor recommends. If you are younger than 65 but have chronic lung disease, heart disease, diabetes, or a weakened immune system, you may also need pneumonia shots.
If you had a pneumonia shot years ago, you might need a new one now because vaccine recommendations have changed. The best way to know what you need is to ask your doctor or call your pharmacy and describe your age and health conditions. They can tell you whether you need a shot and which one.
Do not assume you have already had all the shots you need. Many people who got a pneumonia shot 10 or 20 years ago now may have access to for a different or additional vaccine based on newer guidelines.
What to do if the pharmacy says Medicare will not pay
If a pharmacy tells you Medicare will not cover the shot, ask them to check again or call Medicare directly at 1-800-MEDICARE (1-800-633-4227). Pneumonia shots are a covered preventive service, so the issue is usually that the pharmacy is not billing correctly or the pharmacist is not a may have access to provider under Medicare rules.
Some pharmacies employ pharmacists who are not set up to bill Medicare directly. In that case, you can ask the pharmacy to refer you to another location or another pharmacy that can bill Medicare, or you can go to your doctor's office instead. Your doctor's office can give you the shot and bill Medicare the same way.
If you end up paying out of pocket because of a billing error, keep your receipt. You may be able to get reimbursed by contacting Medicare or your pharmacy's billing department later.
Pneumonia shots and other Medicare coverage
If you have Medicare Advantage (Part C) instead of Original Medicare, your plan covers pneumonia shots at no cost as well, though you may need to use in-network providers. Check your plan documents or call the plan to confirm which pharmacies are in your network.
If you have Medicaid in addition to Medicare, Medicaid may also cover the shot. Bring both cards to the pharmacy so they can bill correctly. Some pharmacies will bill Medicare first and then Medicaid for any remaining cost, though pneumonia shots should have no cost under either program.
Pneumonia shots are separate from flu shots and COVID-19 vaccines, which Medicare also covers at no cost. You can get a pneumonia shot at the same visit as a flu shot, though some people prefer to space them out by a week or two to avoid arm soreness from multiple shots.
When to talk to your doctor instead of going to the pharmacy
Go to your doctor instead of the pharmacy if you have had a severe allergic reaction to a vaccine before, if you are currently sick with a fever, or if you take medications that weaken your immune system and want to discuss timing. Your doctor can review your medical history more thoroughly and tell you whether now is the right time for the shot.
You should also see your doctor if you are not sure whether you have had pneumonia shots in the past or if you have questions about which vaccine you need. Your doctor's office can check your records and make a recommendation based on your specific health situation.
If you have a reaction to the shot — such as fever, severe arm swelling, or difficulty breathing — contact your doctor or go to urgent care. Serious reactions are rare, but your doctor should know about them.
Frequently Asked Questions
Do I need an appointment to get a pneumonia shot at a pharmacy?
Most pharmacies do not require an appointment for pneumonia shots, but calling ahead is still a good idea so they can confirm they have the vaccine in stock and know you are coming. Some busy locations may ask you to schedule a time to avoid a long wait.
Will the pneumonia shot hurt?
The shot itself is a quick needle in the arm, similar to a flu shot. Most people feel only mild discomfort. Arm soreness for a day or two afterward is common but not serious. Fever or body aches are less common and usually mild if they happen.
Can I get a pneumonia shot if I just had the flu shot?
Yes, you can get a pneumonia shot at the same visit as a flu shot or any other vaccine. Some people choose to get them at different times to avoid multiple sore arms on the same day, but there is no medical reason to wait. Ask the pharmacist what they recommend.
What if I do not know whether I have had a pneumonia shot before?
Tell the pharmacist you are not sure. They can ask you when and where you might have had it, and they can check your pharmacy records if you have used the same pharmacy before. If there is any doubt, the pharmacist can contact your doctor's office to check your medical records.
Does Medicare cover pneumonia shots if I get them while traveling?
Yes, as long as you go to a Medicare-participating pharmacy or provider. If you are traveling out of state, call ahead to find a network pharmacy near where you will be, or go to an urgent care clinic or hospital that accepts Medicare. Bring your Medicare card with you.