Coverage and Reimbursement

Medicare and Managed Care Coverage

Commercial Plans
  • Each plan decides its own coverage and reimbursement rate, which varies based on plan and patient group. Pfizer suggests that you contact the plan to determine reimbursement.
Medicare Part B Patients
  • Prevnar 13® is covered for all eligible Medicare patients via their Part B fee-for-service benefit1
  • Prevnar 13® is available to Medicare Part B patients with $0 in out-of-pocket costs for the vaccine2
  • The CPT® code* for Prevnar 13® is 906702
  • The allowed amount for the administration of the pneumococcal vaccines is based on the same rate as the commercial provider HCPCS code 90471 (Immunization Administration, Hepatitis B Virus (HBV) Vaccine) as priced on the physician fee schedule database. When billing Medicare, providers will submit G0009 for the administration of the vaccine2
  • The allowable fee for the administration of the seasonal influenza virus and/or pneumococcal vaccines will vary based on the locality of the provider
  • If you have a question about reimbursement rates for pneumococcal vaccination in your office, contact your local Medicare Administrative Contractor (MAC) Web site or customer service line provided by clicking on your state in the map below

Coverage Map

Click on your state in the map below for information on how to contact your local MAC provider and for directions on how to locate reimbursement rates for Prevnar 13®.

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

INDICATIONS

  • Prevnar 13® is a vaccine indicated for active immunization for the prevention of disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F
  • In adults 50 years and older for pneumococcal pneumonia and invasive disease. Indication is
    based on immune responses
  • In children 6 weeks through 17 years for invasive disease caused by the 13 serotypes, and for
    children 6 weeks through 5 years of age for otitis media caused by 7 of the 13 serotypes only
    (4, 6B, 9V, 14, 18C, 19F, and 23F)

Limitations of Use and Effectiveness

  • Prevnar 13® will only help protect against S pneumoniae serotypes in the vaccine
  • Effectiveness when administered <5 years after pneumococcal polysaccharide vaccine is not known

IMPORTANT SAFETY INFORMATION

  • 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, antibody responses to Prevnar 13® were diminished when given with inactivated
    Influenza Virus Vaccine
  • In adults, the commonly reported solicited adverse reactions were pain, redness, and swelling at
    the injection site, limitation of arm movement, fatigue, headache, muscle or joint pain, decreased
    appetite, chills, or rash
  • Apnea following intramuscular vaccination has been observed in some infants born prematurely. Vaccination of premature infants should be based on the infant’s medical status, and the potential benefits and risks
  • In infants and toddlers, the most commonly reported serious adverse events were bronchiolitis (0.9%), gastroenteritis (0.9%), and pneumonia (0.9%)
  • In children 6 weeks through 17 years, the most commonly reported solicited adverse reactions were injection site tenderness, redness, or swelling, irritability, decreased appetite, decreased
    or increased sleep, and fever. Most commonly reported side effects in children 5 years through
    17 years also included hives

Please see full Prescribing Information for Prevnar 13®

These documents are in PDF (portable document format).
PDF files require Adobe Reader. Click here to download this free program.

References:
1. Centers for Medicare & Medicaid Services. Medicare: adult immunization overview.
http://www.cms.gov/Immunizations. Accessed March 5, 2012. 2. Centers for Medicare and Medicaid Services. 2012-2013 immunizers’ question and answer guide to Medicare Part B, Medicaid and CHIP coverage of seasonal influenza and pneumococcal vaccinations: steps to promoting wellness immunizations. http://www.cms.gov/Medicare/Prevention/Immunizations/Downloads/2012-2013_Flu_Guide.pdf. Accessed February 11, 2013.

Please scroll for Important Safety Information and Indications

IMPORTANT SAFETY INFORMATION

  • 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, antibody responses to Prevnar 13® were diminished when given with inactivated Influenza Virus Vaccine
  • In adults, the commonly reported solicited adverse reactions were pain, redness, and swelling at the injection site, limitation of arm movement, fatigue, headache, muscle or joint pain, decreased appetite, chills, or rash
  • Apnea following intramuscular vaccination has been observed in some infants born prematurely. Vaccination of premature infants should be based on the infant’s medical status, and the potential benefits and risks
  • In infants and toddlers, the most commonly reported serious adverse events were bronchiolitis (0.9%), gastroenteritis (0.9%), and pneumonia (0.9%)
  • In children 6 weeks through 17 years, the most commonly reported solicited adverse reactions were injection site tenderness, redness, or swelling, irritability, decreased appetite, decreased or increased sleep, and fever. Most commonly reported side effects in children 5 years through 17 years also included hives

INDICATIONS

  • Prevnar 13® is a vaccine indicated for active immunization for the prevention of disease caused by Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F
  • In adults 50 years and older for pneumococcal pneumonia and invasive disease. Indication is based on immune responses
  • In children 6 weeks through 17 years for invasive disease caused by the 13 serotypes, and for children 6 weeks through 5 years of age for otitis media caused by 7 of the 13 serotypes only (4, 6B, 9V, 14, 18C, 19F, and 23F)

Limitations of Use and Effectiveness

  • Prevnar 13® will only help protect against S pneumoniae serotypes in the vaccine
  • Effectiveness when administered <5 years after pneumococcal polysaccharide vaccine is not known

Please see full Prescribing Information for Prevnar 13®