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.
Vaccines Covered By Medicare Part D
Medicare Part D covers all commercially available vaccines needed to prevent illness. You can get Part D coverage through a stand-alone Medicare prescription drug plan or a Medicare Advantage plan that includes drug coverage.
Vaccines covered by Part D include the following:
- Shingles vaccine: One-time vaccine given in two shots over two to six months
- Tdap vaccine : One shot if youve never been vaccinated, and a booster every ten years
- Other vaccines covered: Vaccines that are “reasonable and necessary” to prevent illness and are not covered by Part B
Part D may also cover vaccines you may need if you are traveling internationally. Talk with your doctor about your travel plans and ask what vaccines are recommended.
Medicare Coverage And Payment
Medicare covers initial pneumococcal vaccine and different, second pneumococcal vaccine one year after the first is administered, effective February 2, 2015. See Modifications to Medicare Part B Coverage of Pneumococcal Vaccinationspdf iconexternal icon.
Medicare Part B will pay for the following vaccines:
- Influenza vaccine
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Whats The Difference Between Vaccine And Immunization
Theres a lot of medical terminology out there. And spoiler alert many terms may mean the same thing, which is the case here. A vaccine is something that may fire up your immune system so it can produce immunity to a specific illness. Its usually given through an injection . A vaccination or immunization is simply the act of giving a vaccine. And once you have immunity to a specific illness, you may be protected from getting it even if exposed.2
Who Should Not Get These Vaccines
Because of age or health conditions, some people should not get certain vaccines or should wait before getting them. Read the guidelines below specific to pneumococcal vaccines and ask your or your childs doctor for more information.
Children younger than 2 years old should not get PPSV23. In addition, tell the person who is giving you or your child a pneumococcal conjugate vaccine if:
You or your child have had a life-threatening allergic reaction or have a severe allergy.
- Anyone who has had a life-threatening allergic reaction to any of the following should not get PCV13:
- A shot of this vaccine
- An earlier pneumococcal conjugate vaccine called PCV7
- Any vaccine containing diphtheria toxoid
You or your child are not feeling well.
- People who have a mild illness, such as a cold, can probably get vaccinated. People who have a more serious illness should probably wait until they recover. Your or your childs doctor can advise you.
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Is It Cheaper To Get A Vaccine At My Doctors Office Or A Pharmacy
You may feel more comfortable getting shots at your healthcare providers office. Your provider knows your patient history and can provide a one-on-one experience. If you choose to get vaccinated at your providers office, keep in mind you may be billed for an office visit in addition to the cost of the shot.
For the COVID-19 vaccine, your provider shouldnt charge you if the vaccine was the only service you received. You should ask for a refund if you believe you were billed in error for the COVID-19 vaccine.
You can also get immunizations against flu, pneumonia, shingles, and other conditions at your local pharmacy. Youll be responsible for any copays or deductibles depending on your prescription drug plan, but you wont have an office visit copay.
Plus, your vaccine record will be kept on file as part of your permanent pharmacy history. When you get vaccinated at your pharmacy, your information is entered into the state immunization registry, which can be accessed by your doctor, Dr. Schaffner says.
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?
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Who Should Get Pneumococcal Vaccines
CDC recommends pneumococcal vaccination for all children younger than 2 years old and all adults 65 years or older. In certain situations, older children and other adults should also get pneumococcal vaccines. Below is more information about who should and should not get each type of pneumococcal vaccine.
Talk to your or your childs doctor about what is best for your specific situation.
Medicare Coverage For The Pneumonia Shot
Part B of Original Medicare does cover the pneumonia vaccine, but there are certain limitations, according to Medicare.gov:
- Medicare Part B covers one shot. Anybody who is enrolled in Part B is entitled to a dose of pneumonia vaccine without having to pay for it if your health-care provider accepts Medicare assignment.
- Under certain circumstances, a doctor may prescribe a second shot of a different typeat least one year after the first dose. Part B may also cover this second dose.
- In either situation described above, you typically wont have out-of-pocket costs as a Part B beneficiary.
In some cases, a doctor may recommend more doses than the amount that Part B pays for. For example, a doctor may suggest a second dose of the PPSV23 vaccine. In this case, its possible that a Medicare Supplement or Medicare Advantage plan will provide coverage. Otherwise, you might have to pay for these additional services out of pocket. If the cost is a concern, its a good idea to contact Medicare or your Medicare plan to learn how these additional services will be covered or if they will be covered at all.
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What Is Pneumococcal Polysaccharides Vaccine
Pneumococcal disease is a serious infection caused by a bacteria that can infect the sinuses, inner ear, lungs, blood, and brain. These conditions can be fatal.
Pneumococcal polysaccharides vaccine is used to help prevent disease caused by pneumococcal bacteria. This vaccine contains 23 different types of pneumococcal bacteria.
PPSV is for use in adults 50 years and older, and in people at least 2 years old who have an increased risk of developing pneumococcal disease due to certain medical conditions.
The Centers for Disease Control and Prevention recommends this vaccine in adults 65 years and older even if they had a pneumococcal vaccine before the age of 65.
This vaccine helps your body develop immunity to the disease, but will not treat an active infection you already have.
Like any vaccine, pneumococcal polysaccharides vaccine may not provide protection from disease in every person.
Common And Local Adverse Events
Pneumococcal conjugate vaccine
Studies of Pneu-C-13 vaccine indicated that irritability decreased appetite increased or decreased sleep and pain, swelling and redness at the injection site after the toddler dose and in older children, are common side effects. Low grade fever occurred in 20% to 30% or more of vaccine recipients. In adults over 50 years of age, the most commonly reported side effects included pain at the injection site, fatigue, headache and new onset of myalgia, with fever above 38Â°C occurring in approximately 3% of vaccine recipients.
Pneumococcal polysaccharide vaccine
Reactions to Pneu-P-23 vaccine are usually mild. Soreness, redness and swelling at the injection site occur in 30% to 60% of vaccine recipients and more commonly follow SC administration than IM administration. Occasionally, low grade fever may occur. Re-immunization of healthy adults less than 2 years after the initial dose is associated with increased injection site and systemic reactions. Studies have suggested that re-vaccination after an interval of at least 4 years is not associated with an increased incidence of adverse side effects. However, severe injection site reactions, including reports of injection site cellulitis and peripheral edema in the injected extremity, have been documented rarely with Pneu-P-23 vaccine in post-marketing surveillance, even with the first dose. Multiple re-vaccinations are not recommended refer to Booster doses and re-immunization.
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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.
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How Does Herd Immunity Work
Herd immunity is used by the Centers for Disease Control and Prevention to describe when enough people within a single community become immune to an infectious disease through vaccination or from previous illness. This may slow the spread of disease and even might make it unlikely to spread at all.3 The percentage of people who may need to have protection in order to achieve herd immunity may vary by disease.
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What Vaccines Does Medicare Cover
Vaccines can become less effective over time. Even individuals fully vaccinated as children may need to update their immunizations. Medicare Parts B and D offer vaccination coverage.
Medicare Part B covers shots for the flu, hepatitis B, pneumococcal , and COVID-19. Medicare covers 100 percent of the cost of these vaccines if you go to an approved provider, and you do not have to pay a deductible or coinsurance. Medicare Advantage plans are also required to provide these vaccines at no additional costs.
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Medicare covers one flu shot per flu season, which runs from November to April, and not the calendar year. For example, if an individual gets a flu shot in January and again in November of the same year, Medicare would pay for both.
Medicare covers two different pneumonia shots. Medicare recipients can get the first shot at any time and it will cover the second shot if it’s administered at least one year after the first shot.
Hepatitis B shots are free for anyone considered medium or high risk for contracting the virus. End-stage renal disease and diabetes are two conditions that place individuals into a higher risk category. A medical professional can help determine an individuals risk level.
Keeping current on your vaccinations is one of the best ways to prevent serious illness and disease. Talk with your doctor to determine what vaccines you need to minimize risks to your health.
Whats 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.
Getting one or both pneumonia shots is one step toward preventing this condition. Pneumonia shots also help protect you from pneumococcal complications, such as meningitis and bacteremia.
Pneumonia can result from the flu, so another important step is getting an annual flu shot.
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Concurrent Administration Of Vaccines
Pneumococcal vaccines may be administered concomitantly with other vaccines, with the exception of a different formulation of pneumococcal vaccine . There should be at least an 8 week interval between a dose of pneumococcal conjugate vaccine and a subsequent dose of Pneu-P-23 vaccine, and at least a 1 year interval between a dose of Pneu-P-23 vaccine and a subsequent dose of pneumococcal conjugate vaccine refer to Immunocompromised persons for information regarding administration of pneumococcal vaccines to HSCT recipients. Different injection sites and separate needles and syringes must be used for concurrent parenteral injections. Refer to Timing of Vaccine Administration in Part 1 for additional information about concurrent administration of vaccines.
How Much Do Vaccines And Shots Cost With Insurance
Without health insurance, shots and vaccines are paid out-of-pocket. This means something like the shingles vaccine could cost you around $200 if you are uninsured.
With insurance, many preventive shots are covered, although you are still responsible for any copay or deductible your health plan has. The cost of vaccines and shots depends on two factors: the type of shot or vaccine, and your insurance coverage.
For Blue Cross Blue Shield plans offered by CareFirst, vaccinations are completely free. You will pay no out-of-pocket copayment or coinsurance, and you will not have to pay toward your deductible.
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Does Medicare Pay For The Pneumonia Shot
En español | Yes, Medicare Part B pays for this shot. This shot helps prevent pneumonia. Most people only need this shot once in their lifetime. Talk with your health care provider to see if you should get the shot. You will not have to pay a deductible or copayment to receive this shot as long as you see doctors or pharmacists who accept Medicare.
Medicare Advantage Plans May Cover More Vaccines Than Original Medicare
Medicare Advantage plans are sold by private insurance companies as an alternative to Original Medicare.
Every Medicare Advantage plan must provide the same hospital and medical benefits as Medicare Part A and Part B, and most plans include Medicare prescription drug coverage.
MAPDs must help cover a number of commercially available vaccines that arent covered by Original Medicare when reasonably and medically necessary to prevent illness. However, specific rules of administration and costs will vary depending on the Medicare Advantage plan you enroll in.
A licensed insurance agent can help you compare Medicare Advantage plans in your area, including what vaccinations may be covered.
Find Medicare plans that cover your vaccinations
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About the author
Christian Worstell is a licensed insurance agent and a Senior Staff Writer for MedicareAdvantage.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.
His work has been featured in outlets such as Vox, MSN, and The Washington Post, and he is a frequent contributor to health care and finance blogs.
Christian is a graduate of Shippensburg University with a bachelors degree in journalism. He currently lives in Raleigh, NC.
Where you’ve seen coverage of Christian’s research and reports:
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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.
When To Get Your Shots
The best time to get your flu and pneumonia shots is any time after July 1 each year. This is because flu season typically begins in the fall. Peak months for the flu season in Michigan are November, December, January, February, March and April.
The flu spreads quickly during those peak months. So, getting vaccinated early is important, because it gives your body a chance to protect itself.
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Adults At High Risk Of Ipd
Adults with immunocompromising conditions resulting in high risk of IPD, except HSCT, should receive 1 dose of Pneu-C-13 vaccine followed at least 8 weeks later by 1 dose of Pneu-P-23 vaccine, if not previously received. The dose of Pneu-C-13 vaccine should be administered at least 1 year after any previous dose of Pneu-P-23 vaccine. Refer to Immunocompromised persons for information about immunization of HSCT recipients.
Immunocompetent adults with conditions or lifestyle factors resulting in high risk of IPD should receive 1 dose of Pneu-P-23 vaccine, if not previously received. One dose of Pneu-P-23 vaccine is also recommended for all adults who are residents of long-term care facilities and should be considered for individuals who use illicit drugs.
Some experts also suggest a dose of Pneu-C-13 vaccine, followed by Pneu-P-23 vaccine, for immunocompetent adults with conditions resulting in high risk of IPD as this may theoretically improve antibody response and immunologic memory. However, Pneu-P-23 vaccine is the vaccine of choice for these individuals, and if only one vaccine can be provided, it should be Pneu-P-23 vaccine, because of the greater number of serotypes included in the vaccine.
Adults at highest risk of IPD should also receive 1 booster dose of Pneu-P-23 vaccine refer to Booster doses and re-immunization.
Table 4 – provides recommended schedules for adult immunization with pneumococcal vaccines.