Doctors use the Prevnar 13 vaccine to protect people against pneumococcal disease, including pneumonia. Medicare covers the vaccination in full, and there are usually no out-of-pocket expenses.

Pneumonia is a lung infection that causes inflammation and a buildup of pus and fluid, making it difficult to breathe.

It is a common illness with symptoms that range in severity from mild to life threatening. According to the Centers for Disease Control and Prevention (CDC), it was responsible for 1.3 million trips to the emergency department in the United States in 2017.

Part B of the federal insurance program Medicare covers the full cost of the Prevnar 13 vaccine. People with Medicare Advantage (Part C) plans also have this benefit.

We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:

  • Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
  • Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
  • Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
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Original Medicare Part B covers the full cost of Prevnar 13, providing that a doctor recommends the vaccination. Part B also covers the pneumonia vaccine Pneumovax 23, seasonal flu shots, and hepatitis B shots for those at high risk.

To ensure that there are no out-of-pocket costs, a person must visit a Medicare-approved provider for their vaccination, such as a participating doctor or pharmacist.

The Medicare website has a helpful tool for finding approved providers in specific areas.

For most other preventive vaccines, Medicare Part D prescription drug plans cover the costs. A person can add a Part D plan to original Medicare, which is Part A and Part B.

Private insurance companies administer Part D plans, each of which covers different medications in its drug list, known as a formulary.

As with Part D, private insurance companies administer Medicare Advantage plans. Legally, Medicare Advantage plans must offer the same coverage as original Medicare. Therefore, an individual with a Medicare Advantage plan will have coverage for the Prevnar 13 vaccine, but they may need to use an in-network provider.

Prevnar 13 is a vaccine that protects against pneumococcal disease.

Streptococcus pneumonia is a bacterium that can cause various infections, ranging from mild ear and sinus infections to dangerous pneumonia and bloodstream infections.

Many strains of these bacteria exist, and Prevnar 13 protects against 13 of the most common. The Pneumovax 23 vaccine protects against 12 of the same strains as Prevnar 13, plus 11 additional ones.

CDC data show that Prevnar 13 is up to 75% effective in protecting people aged 65 years and over against pneumococcal disease.

Initially, in 2014, the CDC Advisory Committee on Immunization Practices (ACIP) recommended routine Prevnar 13 vaccination ahead of Pneumovax 23 vaccination a year later for those aged 65 years and over.

In 2019, the ACIP changed the recommendation to a single dose of Pneumovax 23 because the routine vaccination of children has caused a decline in the bacterial strains that commonly cause disease.

However, the ACIP recognized that some older people should still receive Prevnar 13, including those who:

  • live in a nursing home or another long-term care facility
  • have cochlear implants
  • are immunocompromised and have never received a pneumonia vaccine
  • have a cerebrospinal fluid leak
  • visit areas where doctors do not routinely vaccinate children with Prevnar 13

Medicare Part B covers 100% of the costs for Prevnar 13. Individuals do not pay a copayment or coinsurance, as long as they use a Medicare-approved provider.

The Part B deductible does not apply to the Prevnar 13 and Pneumovax 23 vaccinations. Therefore, the beneficiary should not receive a bill or have to pay any costs upfront.

The only cost is the Part B monthly premium. In 2021, the standard premium is $148.50.

Medicare Advantage

If a person has a Medicare Advantage plan, they will not pay any out-of-pocket costs, providing they use an in-network provider.

Individuals must still pay their Part B premium and the Medicare Advantage plan premium, which can vary according to the person’s location, personal circumstances, and specific plan. According to the Kaiser Family Foundation, in 2020, the average Medicare Advantage premium was $25 per month.

While there are generally no costs to pay for Prevnar 13, a person may need assistance with general Medicare expenses.

Help with premiums and other out-of-pocket costs is available through different programs, such as:

  • Medicaid: This government-funded program for people from lower income households helps those of all ages cover their costs.
  • Medicare savings programs: For those who qualify, four different plans are available through Medicare to help with premiums and, in some instances, deductibles, coinsurance, and copayments, too.
  • Extra Help: This Medicare program helps with costs related to prescription medications.

Medicare covers the entire cost of Prevnar 13 vaccinations with no out-of-pocket expenses for those with Medicare Part B or a Medicare Advantage plan.

Individuals must use a Medicare-approved provider for full coverage. Those with a Medicare Advantage plan may need to visit a provider within their plan’s network.

Doctors may recommend that an individual receive the Prevnar 13 vaccine rather than the usual Pneumovax 23 vaccine. In some cases, they may recommend both. Medicare pays for each vaccine if a doctor administers them 1 year apart.