Coverage and reimbursement

Coverage and reimbursement

CMS has updated its policy to cover administration of a different, second pneumococcal vaccine for adults 65+

Click here to learn more about the Centers for Medicare & Medicaid Services (CMS) update.

Prevnar 13® is covered by the Medicare Part B fee-for-service (FFS) benefit, with $0 in out-of-pocket costs, for the following patient types:
  • Adults aged 65+ who were previously vaccinated with PPSV23 at least 1 year prior
  • Adults aged 65+ who are pneumococcal vaccine naive

Provided that the patient is competent, it is acceptable to rely on the patient’s verbal history to determine prior vaccination status.3

PPSV23=23-valent pneumococcal polysaccharide vaccine.

  • Roster billing is permitted for Medicare FFS beneficiaries by mass immunizers, including providers, hospitals, public health clinics, and supermarkets
  • Prevnar 13® and its administration are covered under Medicare Part B beyond the diagnosis-related group (DRG)
Medicare Advantage
  • Medicare Advantage plans, which represent approximately 30% of the total Medicare population, are required to cover services covered through Medicare FFS4,5

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.


 

Coverage map

STEP 2: Choose a state in the drop-down menu for information on how to contact your local provider and for directions on how to locate reimbursement rates for Prevnar 13®

PfizerPrime: How to order

Be prepared: The Advisory Committee on Immunization Practices (ACIP) recommends Prevnar 13® for adults aged 65+1

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References:

  • Centers for Disease Control and Prevention. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥65 years: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2014;63(37):822-825.
  • Prevnar 13® (Pneumococcal 13-valent Conjugate Vaccine [Diphtheria CRM197 Protein]) Prescribing Information, Wyeth Pharmaceuticals, Inc, 2015.
  • 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/Transmittals/Downloads/R202BP.pdf. Accessed January 8, 2015.
  • Henry J. Kaiser Family Foundation. Medicare Advantage fact sheet. http://kff.org/medicare/fact-sheet/medicare-advantage-fact-sheet/. Published May 1, 2014. Accessed January 8, 2015.
  • Centers for Medicare & Medicaid Services. What Medicare health plans cover. http://www.medicare.gov/what-medicare-covers/medicare-health-plans/what-medicare-advantage-plans-cover.html. Accessed February 9, 2015.
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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

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

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.

Please see full Prescribing Information for Prevnar 13®.