Yes, most insurance plans cover the pneumonia vaccine at no cost to you, as long as you meet the recommended age or risk criteria and use an in-network provider. This applies to Medicare, Medicaid, marketplace plans, and most employer-sponsored insurance. The details vary depending on which type of coverage you have.
Medicare Coverage
Medicare Part B covers the pneumococcal vaccine and its administration. This is one of the few vaccines covered under Part B rather than Part D, which means you pay nothing out of pocket: no copay, no coinsurance, and the Part B deductible does not apply. This coverage extends to all CDC-recommended pneumococcal vaccines, including the newer formulations.
Private and Employer-Sponsored Plans
Under the Affordable Care Act, most private health insurance plans must cover CDC-recommended immunizations as preventive services with no cost-sharing. That means no copay, no coinsurance, and no need to meet your deductible first. This applies to marketplace plans, employer-sponsored group plans, and most individually purchased policies.
The key requirement is that you receive the vaccine from an in-network provider. If you go out of network, your plan may not cover it at all, or you could face the full retail price. Most private plans cover the pneumonia vaccine, but the CDC recommends checking with your insurance provider to confirm your specific benefits and find in-network locations.
One important caveat: grandfathered health plans (those that existed before March 2010 and haven’t made certain changes) are not required to cover preventive services at zero cost. If you’re on one of these older plans, you may still owe a copay or coinsurance.
Medicaid Coverage
Medicaid covers the pneumonia vaccine without cost-sharing for most adult beneficiaries. Under rules strengthened by the Inflation Reduction Act, state Medicaid agencies must cover all vaccines recommended by the CDC’s Advisory Committee on Immunization Practices. For adults enrolled through ACA Medicaid expansion, states must cover all immunizations on the CDC adult schedule at no cost. This is a federal requirement, not left to state discretion.
Who Qualifies for Coverage
Insurance coverage of the pneumonia vaccine is tied to CDC recommendations. Currently, the CDC recommends pneumococcal vaccination for two main groups of adults:
- Adults 50 and older: All adults in this age group are recommended to receive a pneumococcal vaccine, regardless of health status.
- Adults under 50 with increased risk: This includes people with weakened immune systems, cochlear implants, cerebrospinal fluid leaks, and certain chronic conditions like diabetes, heart disease, lung disease, or liver disease.
If you fall into one of these groups, your vaccine should be covered as a preventive service. If you’re a healthy adult under 50 without risk factors, the CDC doesn’t currently recommend the vaccine for you, and your insurance is unlikely to cover it.
Which Vaccines Are Covered
The CDC currently recommends three pneumococcal conjugate vaccines for adults: PCV15 (Vaxneuvance), PCV20 (Prevnar 20), and the newer PCV21. Your doctor or pharmacist will recommend the right one based on your vaccination history and risk factors. All CDC-recommended versions are covered under the same preventive care rules, so you shouldn’t face different coverage depending on which one your provider administers.
Where You Get It Can Affect Cost
Even with insurance, where you receive the vaccine can influence total costs to the healthcare system and, in some edge cases, to you. Research comparing vaccination settings found that the average cost paid per pneumonia vaccine administration was lowest at pharmacies ($55), compared to doctor’s offices ($66) and other medical settings ($72). This pattern held across geographic regions and health plan types, with pharmacy-based vaccinations running 16% to 26% cheaper than physician office visits.
For most insured patients receiving a covered preventive vaccine in-network, the cost to you is zero regardless of setting. But if any billing complications arise, or if your plan has unusual terms, pharmacies tend to have simpler and less expensive billing. Most major chain pharmacies accept all common insurance types and can verify your coverage on the spot.
What It Costs Without Insurance
If you don’t have insurance or your plan doesn’t cover the vaccine, the retail price is significant. PCV20 (Prevnar 20) runs around $249 on average, with prices ranging from $127 to $358 depending on the pharmacy and location. PCV15 (Vaxneuvance) averages about $216, ranging from $136 to $356. The older PPSV23 vaccine averages $110, ranging from $49 to $152.
If you’re uninsured, community health centers, local health departments, and pharmacy discount programs may offer reduced pricing. Some vaccine manufacturers also run patient assistance programs that can lower or eliminate the cost for eligible individuals.