Immunization for Pneumonia: Information on Availability, Prices, and Eligibility Criteria
In a bid to protect adults against pneumonia, meningitis, and sepsis, pneumonia shots are recommended for certain individuals. This article provides a detailed overview of the coverage details for these vaccines under Medicare Part B and Medicare Advantage (Part C).
**Medicare Part B Coverage**
All individuals currently enrolled in Medicare Part B are eligible for coverage of the pneumococcal (pneumonia) vaccine. Medicare Part B covers the vaccine at 100% of the reasonable cost, meaning there is generally no deductible, copayment, or coinsurance for the beneficiary.
Typically, Medicare covers one initial pneumococcal shot and may cover a second shot under certain conditions (e.g., if the first was received before age 65). The vaccine is generally covered at doctor’s offices and participating pharmacies that accept Medicare assignment. Starting July 1, 2025, Rural Health Clinics and Federally Qualified Health Centers (RHCs/FQHCs) may bill for Part B preventive vaccines, including pneumococcal, at the time of service, regardless of whether the patient has a qualifying visit.
**Medicare Advantage (Part C) Coverage**
Enrollees in Medicare Advantage plans are also eligible for coverage of the pneumococcal vaccine. By law, Medicare Advantage plans are required to cover the same preventive services as Original Medicare, including the pneumonia vaccine. However, the cost structure (copay, deductible, coinsurance) may vary by plan. Most plans are likely to cover the pneumonia shot at no cost to the member, but members should verify with their specific plan to confirm.
**Comparative Table: Original Medicare Part B vs. Medicare Advantage**
| Feature | Medicare Part B | Medicare Advantage (Part C) | |-------------------------|---------------------------------------------------|----------------------------------------------------| | Eligibility | All Part B enrollees | All plan members | | Vaccine Cost | No deductible, copay, or coinsurance[1][5] | Varies by plan, typically $0, but check your plan[5] | | Where Covered | Doctor’s office, pharmacy (accepting assignment) | Plan’s network of providers | | Frequency | Usually 1 lifetime shot, possibly a 2nd under some conditions | Same as Part B, but subject to plan rules | | Documentation | Routine; part of standard Part B coverage | May require use of plan card; confirm coverage in advance |
**Additional Notes**
- RHCs/FQHCs can bill for pneumococcal vaccine administration separately from the All-Inclusive Rate, and coverage is not subject to the payment limit. - While both Original Medicare and Medicare Advantage should fully cover the pneumonia shot, the member experience (network, billing, proof of coverage) may differ, so Medicare Advantage enrollees should confirm coverage specifics with their plan. - There is generally no requirement for prior authorization for this vaccine under Part B or most Medicare Advantage plans, but always check individual plan documents for confirmation.
For children younger than 5 years old, the recommended pneumococcal vaccine is PCV15 or PCV20. For adults who have never received a PCV, the recommended vaccines are PCV15, PCV20, or PCV21. Adults who received earlier versions of PCV, such as PCV7 or PCV13, should discuss their options with their healthcare professional. If a person receives PCV15, then a follow-up dose of PPSV23 is needed.
It's essential to note that certain individuals should avoid the pneumonia shot under certain conditions, such as those with severe allergies to the PCV15, PCV20, or PCV21 vaccine or the PPSV23 shot. Health risks and chronic conditions that may qualify a person for a pneumonia shot include a weakened immune system, cancer, HIV, those with their spleens removed, asthma, sickle cell disease, and those who smoke.
Rarely, the pneumonia vaccine may cause serious anaphylactic (allergic) reactions. Side effects of the pneumonia shot are usually mild and disappear within a couple of days, and may include skin discoloration, pain, or swelling at the injection site, tiredness, fever, chills, loss of appetite, headache, muscle aches, or joint pain.
Parents or caregivers should speak with the child's healthcare professional about pneumococcal vaccines and the types the child may require, as children with health risks or chronic conditions may require more vaccines than those without these conditions. A Medigap plan may help with costs associated with Part B diagnostic services, including the Part B deductible, coinsurance, and copayments.
- The pneumococcal vaccine, which helps protect adults against pneumonia, is fully covered under Medicare Part B with no deductible, copay, or coinsurance, typically at doctor’s offices and participating pharmacies.
- Medicare Advantage (Part C) enrollees can also receive coverage for the pneumonia vaccine, as per law, but the cost structure may vary by plan, despite them being required to cover the same preventive services.
- In addition to pneumonia, a vaccine for meningitis and sepsis (PPSV23) is often recommended in certain situations, and may be covered under Medicare Part B or Medicare Advantage, although the specifics can differ for each plan.
- Adhering to a healthy lifestyle that includes nutrition, fitness-and-exercise, and overall health-and-wellness practices can complement the effectiveness of immunizations and vaccines in ensuring good health and disease prevention.
