Medicare coverage and Reimbursement

THE CDC'S ACIP RECOMMENDS PREVNAR 13® (PNEUMOCOCCAL 13-VALENT CONJUGATE VACCINE [DIPHTHERIA CRM197 PROTEIN]) FOR IMMUNOCOMPROMISED ADULTS AGED ≥19 AND FOR IMMUNOCOMPETENT ADULTS AGED ≥65 BASED ON SHARED CLINICAL DECISION-MAKING1

Prevnar 13® is a vaccine approved for adults 18 years of age and older for the prevention of pneumococcal pneumonia and invasive disease caused by 13 Streptococcus pneumoniae strains (1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F). Prevnar 13® will only help protect against S. pneumoniae serotypes in the vaccine. Severe allergic reaction (eg, anaphylaxis) to any component of Prevnar 13® or any diphtheria toxoid–containing vaccine is a contraindication.

Prevnar 13® (Pneumococcal 13-valent Conjugate Vaccine [Diphtheria CRM197 Protein]) is covered by the Medicare Part B fee-for-service (FFS) benefit for adults aged 65 and older with $0 in out-of-pocket costs

Medicare covers administration of 2 different pneumococcal vaccines for adults aged 65 and older.2 Prevnar 13® is covered for the following patient types:

Adults aged 65 and older who are pneumococcal vaccine naive

Adults aged 65 and older who were previously vaccinated with Pneumovax® 23 at least 1 year prior

Provided that the patient is competent, it is acceptable to rely on the patient’s verbal history to determine prior vaccination status.2

Announcement Title

Prevnar 13® is covered under Medicare Part B, not Part D3*

*This website is neither owned nor controlled by Pfizer. Pfizer does not endorse and is not responsible for the content or services on this site.

​​​​​​​Pneumovax is a registered trademark of Merck & Co., Inc.

Medicare Advantage

Medicare Advantage plans, which represent approximately 34% of the total Medicare population, are required to cover services covered through Medicare FFS.4,5

As several factors may determine coverage and reimbursement, Pfizer suggests that you contact your Medicare Administrative Contractor (MAC), Medicare Advantage plan, or commercial plan to determine eligibility for specific patients.​​​​​​​

Pfizer Vaccines Reimbursement Support Services

The Pfizer Vaccines Reimbursement Support Services, available to both patients and healthcare providers, can be reached at 1-866-744-3198,
Monday through Friday, between
​​​​​​​8 AM and 8 PM ET

  • Pfizer Vaccines Reimbursement Support Services can help with the following:
    • ​​​​​​​Roster billing
    • Benefits investigation (verifies patient coverage)
    • Prior authorization support (if needed)
    • ​​​​​​​Claims denials/appeals support (if needed)

Coding considerations for Prevnar 13®

  • 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 (DRG) rate for beneficiaries vaccinated during hospitalization

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

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

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

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Support & Order

  • Order and customer service
  • Medicare coverage and reimbursement

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


References

  1. 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 ≥65 years: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019;68:1069-1075. doi: http://dx.doi.org/10.15585/mmwr.mm6846a5.
  2. Department of Health & Human Services (DHHS). CMS Manual System. Pub 100-02 Medicare Benefit Policy. Transmittal 202.
    ​​​​​​​http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittable/Downloads/R202BP.pdf. Accessed January 7, 2020.
  3. Centers for Disease Control and Prevention (CDC). Resources for adult vaccination insurance and payment. http://www.cdc.gov/
    vaccines/hcp/adults/for-practice/insurance-payment.html
    . Accessed January 7, 2020.
  4. Centers for Medicare & Medicaid Services. Medicare Advantage plans cover all Medicare services. https://www.medicare.gov/what-medicare-covers/medicare-health-plans/medicare-advantage-plans-cover-all-medicare-services.html. Accessed January 7, 2020.
  5. The Henry J. Kaiser Family Foundation. Medicare Advantage fact sheet. https://www.kff.org/medicare/fact-sheet/medicare-advantage/#. Accessed January 7, 2020.
  6. Department of Health and Human Services (DHHS). Medicare Part B immunization billing: seasonal influenza virus, pneumococcal, and hepatitis B. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/qr_immun_bill.pdf. Accessed January 7, 2020.
  7. American College of Physicians (ACP). Billing & coding adult immunizations. https://www.acponline.org/system/files/documents/
    ​​​​​​​running_practice/payment_coding/coding/billvaccines.pdf
    . Published 2015. Accessed January 7, 2020.

Indication

  • In adults 18 years of age and older, Prevnar 13® is indicated for active immunization for the prevention of pneumonia and invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F

Limitations of Use and Effectiveness

  • Prevnar 13® will only help protect against S. pneumoniae serotypes in the vaccine
  • Severe allergic reaction (eg, anaphylaxis) to any component of Prevnar 13® or any diphtheria toxoid–containing vaccine is a contraindication
  • Immunocompromised individuals or individuals with impaired immune responsiveness due to the use of immunosuppressive therapy may have reduced antibody response
  • In adults, the most commonly reported solicited adverse reactions were pain, redness, and swelling at the injection site, limitation of arm movement, fatigue, headache, muscle pain, joint pain, decreased appetite, vomiting, fever, chills, and rash

Patients should always ask their doctors for medical advice about adverse events. You are encouraged to report negative side effects of vaccines to the US Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC). Visit www.vaers.hhs.gov or call 1-800-822-7967. This website is neither owned nor controlled by Pfizer. Pfizer does not endorse and is not responsible for the content or services of this site.

Please see full Prescribing Information for Prevnar 13®.

  • In adults 18 years of age and older, Prevnar 13® is indicated for active immunization for the prevention of pneumonia and invasive disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F

Limitations of Use and Effectiveness

  • Prevnar 13® will only help protect against S. pneumoniae serotypes in the vaccine