- Medicare Part B covers the full cost of two pneumonia vaccines: Prevnar 13 (PCV13) and Pneumovax 23 (PPSV23).
- Medicare Part C also covers the full cost of both shots, as long as they’re given by an in-network provider.
- Prevnar 13 is no longer routinely recommended for most people ages 65 and older, unless you have certain conditions or live in a long-term care facility.
Prevnar 13 is a type of pneumonia vaccine. It helps protect against pneumococcal disease caused by 13 strains of a bacteria known as Streptococcus pneumonia.
Pneumococcal disease (pneumonia) symptoms can range from mild to severe and may become serious or life threatening with increasing age. The
Prevnar 13 is one of two pneumococcal vaccines. It’s safe and effective but is no longer recommended for most people ages 65 or over. If your doctor recommends Prevnar 13, you can discuss the pros and cons and decide together if it’s the best choice for you.
If you and your doctor determine together that Prevnar 13 is your best option, Medicare Part B will cover 100 percent of the cost, with no out-of-pocket expense to you.
If you have Medicare Advantage (Part C), your plan will also cover 100 percent of the cost of this vaccine, though you may need to get it from an in-network provider.
Most vaccines required for preventive care are covered under Medicare Part D. Part D is optional prescription drug coverage that you may purchase from a private insurance company.
The two pneumonia vaccines, Prevnar 13 and Pneumovax 23, are covered instead by Medicare Part B. Flu shots are also covered by Part B.
Part B covers preventive care and medically necessary services you receive as an outpatient. Together Medicare Part A and Part B make up what is known as original Medicare.
To get full coverage for Prevnar 13, or any vaccine, you’ll have to go to a Medicare-approved provider. This may be a doctor, pharmacist, or other Medicare-approved professional. You can look up and compare Medicare-approved doctors and hospitals here.
Like Part D, Medicare Part C (Advantage) plans are purchased from private insurance providers. Part C plans must cover at least as much as original Medicare does. If you have a Part C plan, it’ll cover Prevnar 13 as long as you receive it from an in-network provider.
As long as your provider is enrolled in Medicare, Part B will cover the complete cost of Prevnar 13, with no copay or coinsurance required. The Part B deductible doesn’t apply to the pneumonia shot, so you shouldn’t receive a bill or be asked to pay any portion of its cost up front.
If you have Part C, make sure to use an in-network provider. A list of these providers should be available on your plan’s website. If you don’t use an in-network provider, you may get stuck with out-of-pocket costs for Prevnar 13.
Prevnar 13 is a
Prevnar 13 protects against 13 Streptococcus strains.
In 2019, the CDC’s Advisory Committee on Immunization Practices
This change wasn’t based on any problem with the vaccine, but rather on the success of its use in children. Because so many children are now routinely vaccinated with Prevnar 13, the prevalence of the bacterial strains it protects against has sharply declined in the United States.
However, Prevnar 13 is still recommended for certain people ages 65 and over, such as those who:
- have never had a pneumonia vaccine and are immunocompromised due to conditions such as chronic renal failure, nephrotic syndrome, lymphoma, or Hodgkin’s disease
- live with cochlear implants
- live with a cerebrospinal fluid leak
- live in long-term care facilities, such as nursing homes
- travel to areas where children are not routinely given Prevnar 13
If you’ve never had a pneumonia vaccine, your doctor may recommend you get Prevnar 13 first, followed by the Pneumovax 23 (PPSV23) vaccine 1 year later.
You and your doctor may instead decide that you need only Pneumovax 23.
Pneumovax 23 protects against 23 strains of Streptococcus bacterium. These include 12 serotypes that Prevnar 13 protects against, plus 11 additional strains.
If you and your doctor decide that you should get both vaccines, Medicare will pay for them, as long as you receive each vaccine at least 1 year apart from each other.
Pneumonia (pneumococcal disease) is a lung infection that can affect one or both lungs.
Pneumonia may be a complication resulting from the flu. It can also be caused by bacteria, viruses, and fungi.
Pneumococcal pneumonia is the most common type of bacterial pneumonia. This condition infects more than 900,000 people in the United States each year.
What are the symptoms?
If you have pneumonia, your lungs will become inflamed and fill with fluid, making it difficult to breathe. Symptoms of pneumonia include:
- shortness of breath
- lack of alertness
Who’s at highest risk?
Pneumonia symptoms can range from mild to severe.
Since the immune system can weaken with age, people ages 65 over are an at-risk group for severe complications from this condition. Tens of thousands of adults in this age range die from pneumonia each year in the United States.
Your risk for severe symptoms may be higher if you:
- smoke cigarettes or are exposed to secondhand smoke
- misuse alcohol or take recreational drugs
- have a chronic lung disease, such as chronic obstructive pulmonary disease (COPD)
- have trouble swallowing due to a stroke or neurological condition, like dementia
- have a weakened immune system due to conditions such as HIV or AIDS, or from treatments such as chemotherapy or an organ transplant
- have a viral respiratory infection
- are on a ventilator
Call your doctor immediately or go to the emergency room if you have symptoms of pneumonia, especially shortness of breath.
What’s my prognosis after pneumonia?
Healthy people often recuperate from pneumonia at home within 1 to 3 weeks. However, pneumonia is a potentially deadly disease that requires immediate medical input and attention, especially in people over 65 years old.
Pneumonia can result from the flu, so another important step is getting an annual flu shot.
The cost of Prevnar 13 is covered 100 percent by Medicare Part B and Part C. You must use Medicare-approved providers to get full coverage. If you have a Part C plan, make sure to choose an in-network provider.
Prevnar 13 is one of two types of pneumonia shots that your doctor might recommend for you.
It’s typically recommended that people over age 65 get the Pneumovax 23 (PPSV23) vaccine instead of Prevnar 13. In some instances, your doctor may determine, with your input, that you should get Prevnar 13 alone or in addition to Pneumovax 23.
If you require both vaccines, Medicare will pay for them, as long as they’re given at least 1 year apart from each other.
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