Updated Recommendations and Insurance Reimbursement for Pneumococcal Vaccination in those 65 Years and Older

In the September 4, 2015 MMWR, CDC released new pneumococcal vaccination recommendations.

Highlights of the recommendations are outlined below:

  • Both PCV13 and PPSV23 should be administered routinely in a series to all adults aged ≥65 years.  Ideally a single dose of PCV13 should be given first followed by PPSV23.  Specific recommendations are based on a person’s previous pneumococcal vaccine history:

o    Person who are pneumococcal vaccine-naïve. Adults aged ≥65 years who have not previously received pneumococcal vaccine or whose previous vaccination history is unknown should receive a single dose of PCV13 first, followed by a dose of PPSV23. The dose of PPSV23 should be given ≥1 year after a dose of PCV13. If PPSV23 cannot be given during this time window, the dose of PPSV23 should be given during the next visit. The two vaccines should not be coadministered, and the minimum acceptable interval between PCV13 and PPSV23 is 8 weeks.

o    Persons with previous vaccination with PPSV23. Adults aged ≥65 years who have previously received ≥1 doses of PPSV23 also should receive a single dose of PCV13 if they have not yet received it. A dose of PCV13 should be given ≥1 year after receipt of the most recent PPSV23 dose. For those for whom an additional dose of PPSV23 is indicated, this subsequent PPSV23 dose should be given ≥1 year after PCV13 and ≥5 years after the most recent dose of PPSV23.

Additional Resources from CDC

Insurance Coverage and Pneumococcal Vaccines
Most private health insurance covers pneumococcal vaccines.  Patients should check with their insurance provider for details on whether there is any cost to them and for a list of in-network vaccine providers.  If your patients have insurance that supplements Medicare Part B, they should check with them to see if their plan covers both recommended pneumococcal vaccinations.

We have received some updated information from the Centers for Medicare and Medicaid Services (CMS) regarding payment for a second dose of pneumococcal vaccine.  Guidance for providers can be found here: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9051.pdf

The guidance states:

EFFECTIVE DATE: September 19, 2014
*Unless otherwise specified, the effective date is the date of service.

IMPLEMENTATION DATE: February 2, 2015

GENERAL INFORMATION

A. Medicare Part B covers certain vaccinations including pneumococcal vaccines. Generally, pneumococcal vaccine was covered once in a beneficiary’s lifetime, with revaccinations covered for those at highest risk if 5 years have passed since the last vaccination, or if the beneficiary’s vaccination history was unknown.

The ACIP recently updated its guidelines regarding pneumococcal vaccines. The ACIP recommends administration of two different pneumococcal vaccinations.

B. CMS is updating the Medicare coverage requirements to align with the updated ACIP recommendations. An initial pneumococcal vaccine may be administered to all Medicare beneficiaries who have never received a pneumococcal vaccine under Medicare Part B. A different, second pneumococcal vaccine may be administered 1 year after the first vaccine was administered (i.e., 11 full months have passed following the month in which the last pneumococcal vaccine was administered).

Please note that the “interval” between the two different pneumococcal vaccines must be 11 or more months, not 6 months as in the ACIP recommendations.

For Medicare regulations and claims processing, see http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2014-Transmittals-Items/R3159CP.html

Medicare Part B questions: You can send an email to CMS at: sec303ASPData@cms.hhs.gov. Or call the Medicare Call Center at 1-800-MEDICARE (1-800-633-4227).

PLEASE REMEMBER THAT THE MA DEPARTMENT OF PUBLIC HEALTH (MDPH) IMMUNIZATION PROGRAM DOES NOT SUPPLY PCV13 FOR USE IN ADULTS.

If you have questions about the new PCV13 and PPSV23 recommendations for those 65 and older, please call the MDPH Immunization Program at 617-983-6800 and ask to speak to an immunization epidemiologist or immunization nurse.

Page updated October 28, 2015

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