Medicare will cover a second dose of pneumococcal vaccine

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New CMS coverage requirements align with updated ACIP recommendations

Beginning February 2, 2015, CMS will cover a second dose of pneumococcal vaccine to align with updated recommendations from CDC’s Advisory Committee on Immunization Practices (ACIP).

In September 2014, ACIP issued a recommendation to use the existing vaccine (PPSV23) and a recently FDA-approved vaccine (PCV13) in adults 65 years and older for the prevention of pneumococcal disease. Until now, Medicare never paid providers—with the exception of an appropriate booster dose of the same vaccine (PPSV23)—who followed the recommendation to administer a second dose.

“The coverage change will ensure that providers doing the right thing and protecting all adults 65 years and older according to the new ACIP recommendations are not penalized with inadequate payment,” Litjen Tan, MS, PhD, Chief Strategy Officer at the Immunization Action Coalition, told pharmacist.com.

In alignment with ACIP, CMS recommends that the second pneumococcal vaccine be administered 1 year after the first vaccine is administered.

However, Tan said that the CMS guidance is still not completely in sync with the ACIP recommendations. If a provider gives PCV13 first, then PPSV23 can be given after 6–12 months. However, in this case, providers would be advised to wait a year to ensure payment from CMS.

Tan said he is confident CMS is looking into this issue.

In addition, CMS does not require that a physician under Medicare Part B order the pneumococcal vaccine or its administration. Patients can receive the vaccine upon request without their physician’s order or supervision.

“The announced policy change removes a barrier for patient access to an ACIP-recommended vaccination administered by pharmacists and supports completion of the pneumococcal vaccination series,” said Mitchel Rothholz, BSPharm, MBA, APhA’s Chief Strategy Officer. “We thank CMS for the policy change to protect the public from vaccine preventable diseases.”

APhA, along with other immunization stakeholders, advocated for a change to CMS’s Medicare Part B coverage policy related to pneumococcal vaccinations.

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