Knowledge Base Article

Q:

Have the Medicare coverage requirements for pneumococcal vaccinations changed?

A:

Yes, the Advisory Committee on Immunization Practices (ACIP) has issued new recommendations for pneumococcal vaccinations and Medicare has modified their coverage requirements in response to the new recommendations.

As announced in MLN Matters Article MM9051, effective for dates of service on and after September 19, 2014, Medicare will cover the administration of two different pneumococcal vaccinations.

• An initial pneumococcal vaccine to all Medicare beneficiaries who have not previously received a vaccine (based on ACIP recommendations a 13-valent pneumococcal conjugate vaccine – PCV13 should be administered first)
• Followed by a second, different vaccine a year later (23-valent pneumococcal polysaccharide vaccine – PPSV23)

Patients, age 65 and older, who have already received the PPSV23 vaccine, should receive the PCV13 vaccine a year or more after the date of their last PPSV23 vaccine.

These new guidelines differ from the previous coverage of pneumococcal vaccine which was only for individuals at high risk of serious pneumococcal disease (age 65 and older, risk from chronic disease, or immune-compromised patients) with a repeat vaccine after five years for only patients at highest risk (May 1, 1981- September 18, 2014).

Note that a physician’s order is not required for patients to obtain a pneumococcal vaccine.