Medicare coverage and reimbursement

Prevnar 13® 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
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 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)

Coverage by state

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®

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.