Medicare coverage for second pneumococcal vaccination

The Advisory Committee on Immunizations Practices (ACIP) has updated its guidelines regarding pneumococcal vaccines. It now recommends the administration of two different pneumococcal vaccinations.

As a result, the Centers for Medicare & Medicaid Services (CMS) has updated Medicare coverage requirements to align with these guidelines., Priority Health is following CMS recommendations and will now offer coverage for a second pneumococcal vaccination for Medicare members.

Effective immediately, Priority Health will cover:

  • An initial pneumococcal vaccine for all Medicare beneficiaries who have never received the vaccine under Medicare Part B; and
  • A different, second pneumococcal vaccine one year after the first vaccine was administered (that is, 11 full months have passed following the month in which the last pneumococcal vaccine was administered).

For example: if a beneficiary who is 65 years or older received the 23-valent pneumococcal polysaccharide vaccine (PPSV23) a year or more ago, the 13-valent pneumococcal conjugate vaccine (PCV13) should be administered next as the second in the series of the two recommended vaccinations.

Since the updated ACIP guidelines are specific to vaccine type and sequence of vaccination, prior pneumococcal vaccination history should be taken into consideration. Administering multiple vaccinations of the same vaccine type isn't generally recommended. Ideally, providers should have access to vaccination history through electronic health records, to ensure reasonable and necessary pneumococcal vaccinations.

Questions?

Learn more about immunizations under Medicare Parts B and D.