Sunday, September 17, 2023

Does Medicare Pay For Pneumonia Vaccine

Does Medicare Cover Prevnar 13

Medicare & You: Vaccines

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, youll 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 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, itll cover Prevnar 13 as long as you receive it from an in-network provider.

Most Medicare Advantage Plans And Part D Plans Cover Prescription Drugs

Medicare Advantage plans that offer prescription drug coverage are called Medicare Advantage Prescription Drug Plans . Most Medicare Advantage beneficiaries are enrolled in MA-PDs.1

Medicare Part D prescription drug plans also cover retail prescription drugs.

You can compare Part D prescription drug plans available where you live and enroll in a Medicare prescription drug plan online when you visit

Medicare prescription drugs plans each have their own formulary, or drug list, that details what prescription drugs are covered by the plan and how they are covered.

Some Medicare Advantage plans also include benefits such as routine dental, hearing and vision coverage.

A licensed insurance agent can help you learn more about Medicare Advantage plans that are available where you live, including the benefits they offer. $0 premium plans may be available in your area.

1 Jacobson, Gretchen et al. A Dozen Facts About Medicare Advantage. . Kaiser Family Foundation. Retrieved from is a website owned and operated by TZ Insurance Solutions LLC. TZ Insurance Solutions LLC and TruBridge, Inc. represent Medicare Advantage Organizations and Prescription Drug Plans having Medicare contracts enrollment in any plan depends upon contract renewal.

Medicare has neither reviewed nor endorsed this information.

What Is The Pneumonia Vaccine

There are currently two types of pneumococcal vaccines that cover different strains of a common type of bacteria that can lead to pneumonia. This type of bacteria poses risks for young children but can also be risky for those who are older or have compromised immune systems.

The two vaccines are:

  • pneumococcal conjugate vaccine
  • pneumococcal polysaccharide vaccine

According to recent data, the CDC Advisory Committee on Immunization Practices recommend that people who are 65 and older should get the Pneumovax 23 shot.

However, both vaccines may be needed in certain circumstances when there is greater risk. These situations can include:

  • if you live in a nursing home or long-term care facility
  • if you live in an area with many unvaccinated children
  • if you travel to areas with a large population of unvaccinated children

Here is a comparison between the two available vaccines:

Protects against 13 strains of Streptococcus pneumoniae Protects against 23 strains of Streptococcus pneumoniae
No longer routinely given to people 65 and older One dose for anyone 65 years and older
Only given if you and your doctor decide it is needed to protect you from risk, then one dose for those 65 and older If you were already given PCV13, you should get PCV23 at least 1 year later

Pneumonia vaccines can prevent serious infections from the most common strains of pneumococcal bacteria.

Possible side effects

Recommended Reading: Cvs Tdap

Introducing The Tdap Vaccine

TDAP is a vaccine that aims at preventing three life-threatening diseases: namely diphtheria, tetanus, and pertussis .

As a rule of thumb, Medicare plan D covers the expenses of commercially available shots whose purpose is to deter illnesses. To that end, note that Medicare plan B doesnt cover this. Still, there is an exception namely the plan B program will cover the cost of the vaccine granted that it has been recommended by a health professional as a means of treating an injury or illness.

The Above Policy Is Based On The Following References:

How Medicare covers shingles vaccine and other vaccinations
  • Adawi M, Bragazzi NL, McGonagle D, et al. Immunogenicity, safety and tolerability of anti-pneumococcal vaccination in systemic lupus erythematosus patients: An evidence-informed and PRISMA compliant systematic review and meta-analysis. Autoimmun Rev. 2019 18:73-92.
  • American Academy of Pediatrics, Committee on Infectious Diseases. 1997 Red Book: Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics 1997.
  • American Academy of Pediatrics, Committee on Infectious Diseases. Policy statement: Recommendations for the prevention of pneumococcal infections, including the use of pneumococcal conjugate vaccine , pneumococcal polysaccharide vaccine, and antibiotic prophylaxis. Pediatrics. 2000 106:362-366.
  • American Academy of Pediatrics, Committee on Infectious Diseases. Technical report: Prevention of pneumococcal infections, including use of pneumococcal conjugate and polysaccharide vaccines and antibiotic prophylaxis. Pediatrics. 2000 106:367-376.
  • American College of Physicians Task Force on Adult Immunization and Infectious Disease Society of America. Guide for Adult Immunization. 3rd ed. Philadelphia, PA: American College of Physicians 1994.
  • Anderson HH. Pneumococcal vaccination in elderly and at-risk patients. Am Fam Physician. 1998 57:2346.
  • Berman-Rosa M, O’Donnell S, Barker M, Quach C. Efficacy and effectiveness of the PCV-10 and PCV-13 vaccines against invasive pneumococcal disease. Pediatrics. 2020 145:e20190377.
  • Also Check: Tdap Cvs

    Should You Get A Flu Shot

    In general, every person with diabetes needs a flu shot each year. Talk with your doctor about having a flu shot. Flu shots do not give 100% protection, but they do make it less likely for you to catch the flu for about six months.

    For extra safety, it’s a good idea for the people you live with or spend a lot of time with to get a flu shot, too. You are less likely to get the flu if the people around you don’t have it.

    The best time to get your flu shot is beginning in September. The shot takes about two weeks to take effect.

    If youre sick , ask if you should wait until you are healthy again before having your flu shot. And don’t get a flu shot if you are allergic to eggs.

    You are advised to continue to take the general precautions of preventing seasonal flu and other communicable illnesses and diseases:

    • Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash. If you dont have a tissue, cough or sneeze into your elbow, not your hand.
    • Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
    • Avoid touching your eyes, nose, or mouth. Germs spread that way.
    • Try to avoid close contact with sick people.
    • If you get sick, stay home from work or school and limit contact with others to keep from infecting them.

    Vaccine Coverage Through Medicare Part D

    Generally, Medicare prescription drug coverage covers all commercially available vaccines needed to prevent illness. To be safe, you should always check with your plans Member Services team first if youre thinking about getting a specific vaccine.

    You can get Part D coverage through a stand-alone prescription drug plan, or through a Medicare health plan like Medicare Advantage. If you dont have prescription drug coverage, you might have to pay full price for the other vaccines you need or want.

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    Who Should Avoid Pneumococcal Vaccinations

    Because of age or certain health conditions, some people should avoid or delay getting a pneumonia shot. This varies based on your situation and the type of vaccine.

    When to Avoid or Delay Pneumococcal Vaccination

    Prevnar 13
    • If you are allergic to any part of the vaccine.
    • If you have had a life-threatening reaction to this vaccine in the past.

    If you have a serious illness, you should talk with your doctor about whether its safe to get a pneumonia shot or whether you should wait.

    Prepare for the Medicare Advantage Open Enrollment Period

    Does Medicare Cover The Hepatitis B Vaccine

    Medicare Vaccinations for Medical Coders

    Medicare Part B and Medicare Advantage plans will cover injection of the Hepatitis B vaccine if you are considered at medium or high risk for Hepatitis B.

    You may have an increased risk if:

    • You have hemophilia
    • You live with another person who has Hepatitis B
    • You work in health care and have frequent contact with blood and other bodily fluids

    Your doctor can help you determine if youre at increased risk for contracting Hepatitis B.

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    Medicare Coverage For The Pneumonia Vaccine

    Most preventive vaccines are covered under Part D, the prescription drug part of Medicare. Medicare Part B covers a few specific vaccines, like the two pneumonia vaccines. Medicare Advantage plans, sometimes called Part C, also cover the pneumonia vaccines, along with other vaccines you may need.

    If you are enrolled in original Medicare , or a Part C plan, you are automatically eligible for the pneumonia vaccines. Since there are two types of vaccines for pneumonia, you and your doctor will decide if you need one or both vaccines. Well get into the details of the two different types a little later.

    How Much Does Prevnar 13 Cost

    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 doesnt apply to the pneumonia shot, so you shouldnt 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 plans website. If you dont use an in-network provider, you may get stuck with out-of-pocket costs for Prevnar 13.

    vaccine. It protects against pneumococcal disease caused by Streptococcus pneumonia. This is a type of a bacteria that has more than 90 different strains.

    Prevnar 13 protects against 13 Streptococcus strains.

    In 2019, the CDCs Advisory Committee on Immunization Practices changed its recommendations for immunization with Prevnar 13 in people over age 65.

    This change wasnt 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:

    • 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

    You and your doctor may instead decide that you need only Pneumovax 23.

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    Whats Included In Medicare Vaccine Coverage

    Original Medicare covers several common vaccines, but you may need to meet certain eligibility requirements first. For instance:

    • Pneumococcal Vaccine: You can receive the first shot at any time, but inorder to receive a second one, you must get it within one year of the first.
    • HepatitisB Vaccine: Your doctor must determine that youre at a medium or higherrisk in order to receive the Hep B vaccine. Factors that may increase your riskinclude if you live with someone who has the virus, you have diabetes,hemophilia, or End-Stage Renal Disease, or if you work in a health careenvironment and regularly come in contact with bodily fluids.

    You may be able to receive the vaccines covered under Original Medicare at your doctors office or at a nearby pharmacy. You should consult with your healthcare professional ahead of time to ensure that they accept Medicare, and that you meet any necessary eligibility guidelines. Youll typically be able to receive covered vaccines at no additional cost, as long as your healthcare provider accepts Medicares payment terms.

    Coding Considerations For Prevnar 13

    Why Does My Shingles Vaccine Cost So Much?
    • Roster billing is permitted for Medicare FFS patients in hospitals. Only Medicare FFS beneficiaries are eligible
    • Both the Prevnar 13® vaccine and its administration are covered under Medicare Part B separate from the diagnosis-related group rate for beneficiaries vaccinated during hospitalization

    *CPT is a registered trademark of the American Medical Association .

    ââââââ â Additional ICD-10 codes may be needed depending on the type of patient visit and for immunizations administered during inpatient care.

    âââââââ ACIP=Advisory Committee on Immunization Practices CDC=Centers for Disease Control and Prevention.

    Order Prevnar 13®

    ** This is an optional area where footnotes can live.


  • Matanock A, Lee G, Gierke R, Kobayashi M, Leidner A, Pilishvili T. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged â¥65 years: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019 68:1069-1075. doi:
  • Department of Health & Human Services . CMS Manual System. Pub 100-02 Medicare Benefit Policy. Transmittal 202. âââââââ. Accessed January 7, 2020.
  • Centers for Disease Control and Prevention . Resources for adult vaccination insurance and payment. . Accessed January 7, 2020.
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    Pneumococcal Vaccination Among Us Medicare Beneficiaries Aged 65 Years 2010

    : Jessica Hoehner, MPH1 Hilda Razzaghi, PhD2 Walter W. Williams, MD, MPH2 Miwako Kobayashi, MD, MPH3 Tara C. Jatlaoui, MD, MPH2 Xiyuan Wu, MS4 Thomas E. MaCurdy, PhD4,5 Jeffrey A. Kelman, MD6

    1 Leidos, Inc., Atlanta, GA 2Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC 3Division of Bacterial Disease, National Center for Immunization and Respiratory Diseases, CDC 4Acumen, LLC, Burlingame, California 5 Department of Economics, Stanford University 6Center for Medicare, Centers for Medicare & Medicaid Services

    Who Should Get The Pneumonia Shot

    The U.S. Centers for Disease Control and Prevention recommends that everyone over the age of 65 which includes most Medicare beneficiaries should get the Pneumovax 23 vaccine.

    Who Should Get the Pneumovax 23 Shot?

    • All people age 65 or older
    • Cigarette smokers between the ages of 19 through 64
    • People between 2 and 64 years old with certain medical conditions

    The Prevnar 13 vaccine is generally recommended for children younger than 2 years old or for older people with certain medical conditions.

    The CDC suggests anyone 65 and older can ask for the Prevnar 13 vaccine if they decide with their doctor that it would be beneficial to them.

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    Medicare And Tdap Vaccines

    When it comes to vaccination, most people associate it with children or early age, at the very least. Rarely do they attribute vaccination to adults. And even if it is true that a given number of vaccines are expressly targeted for the younger demographic, this doesnt mean that adults shouldnt consider getting vaccinated, when the situation asks of it. Thats because vaccines aim at preventing specific illnesses, no matter the age of the patient.

    Since Medicare acknowledges this, it provides coverage for specific vaccines, as well. But does it cover the expenses of the TDAP vaccine?

    Does Medicare Cover Pneumonia Shots

    Provider Compliance: Medicare Flu Shot Payment & Billing Overview

    Medicare Part B typically covers pneumonia shots, which help prevent certain types of pneumonia.

    Medicare Advantage plans also cover pneumonia shots. Many Medicare Advantage plans also cover prescription drugs and other benefits that Medicare Part A and Part B don’t cover.

    Medicare typically covers 100 percent of the Medicare-approved amount of your pneumococcal vaccine .

    Before getting your pneumonia shot, verify with your doctor that it is 100 percent covered by Medicare.

    The Centers for Disease Control and Prevention recommends PPSV23 pneumococcal vaccinations for all adults who are 65 years of age or older.

    There are currently two pneumococcal vaccines that have been approved for use for the prevention of pneumonia. Both vaccines are covered under Medicare Part B however, the order in which you receive them matters. Talk to your health care provider to learn more.

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    Prevnar 13 And Pneumovax 23

    There are two pneumonia vaccines available: Prevnar 13 and Pneumovax 23. Each shot protects against different strains of bacteria that can cause pneumonia and related complications like meningitis.

    The Prevnar 13 vaccine protects against 13 Streptococcus pneumoniae strains. Doctors may recommend the Prevnar 13 shot for:

    • Some older adults
    • People with underlying immune conditions
    • Those who live in long-term care facilities

    Although Prevnar 13 isn’t necessary for everyone, Medicare does cover the pneumonia shot. Beneficiaries should talk to their doctor about whether to get one or both vaccines.

    How Much Do The Pneumonia Vaccines Cost

    Medicare Part B covers 100% of the cost of the pneumococcal vaccines with no copayments or other costs. Check that your provider accepts Medicare assignment before the visit to ensure full coverage.

    The costs for a Part B plan in 2020 include a monthly premium of $144.60 and a deductible of $198.

    There are many different Medicare Advantage plans offered by private insurance companies. Each come with different costs. Review the benefits and costs of each plan with your specific budget and needs in mind to make the best choice for your situation.

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    Does Medicare Cover The Shingles Vaccine

    En español | Unlike some common vaccines, like those for the flu, hepatitis B and pneumonia, shingles shots are not covered under Medicare Part B, the component of original Medicare that includes doctor visits and outpatient services. Part A, which deals with hospital costs, doesnt cover shingles shots either.

    Medicare coverage for Shingrix and Zostavax, the two commercially available shingles vaccines, is provided only if you are enrolled in a stand-alone Part D drug plan or a Medicare Advantage plan that includes Part D drug coverage.

    Medicare requires Part D plans to cover the shingles vaccine, so if youre enrolled in Part D, you shouldnt have difficulty obtaining the shot. Most require a copayment, which can vary widely from plan to plan.

    And if you havent yet met your plans deductible for the year, youll likely pay the full price. For Shingrix, the newer vaccine, that averages around $190, according to GoodRx, a website and app that tracks prescription prices.

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