PNEUMOVAX 23 is a vaccine indicated for active immunization for the prevention of pneumococcal disease caused by the 23 serotypes contained in the vaccine (1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, and 33F).

Reimbursement, Medicare, & Insurance Coverage Information for PNEUMOVAX 23

PNEUMOVAX 23 CPT® Code

The CPT code for PNEUMOVAX 23 is 90732.

This CPT code is effective as of January 2017 as set forth in the Current Procedural Terminology 2017.

Need CPT codes for other Merck vaccines?

Call the Merck Vaccine Reimbursement Support Center™ at 800.734.6282.

CPT=Current Procedural Terminology.

Current Procedural Terminology© 2019 American Medical Association. All Rights Reserved.

CPT is a registered trademark of the American Medical Association.

Medicare Part B

As of September 19, 2014, Medicare Part B covers16:

  • An initial pneumococcal vaccine for all Medicare beneficiaries aged 65 years and older who have never received the vaccine; and
  • A different, second pneumococcal vaccine 1 year after the first vaccine was administered (11 full months following the month in which the last pneumococcal vaccine was given).

Remember: The reimbursement-related information in this resource is general in nature. This information is subject to change. It is not intended to be exhaustive, nor to replace the guidance of a qualified reimbursement advisor, and does not constitute legal or reimbursement advice. The use of the information presented here is not a guarantee of coverage or payment. As a provider, you are solely responsible for billing payers correctly and for determining whether any payer-specific guidelines apply. Merck does not guarantee or ensure the timeliness or appropriateness of this information for your particular use given the frequent changes in public and private payer billing.

2019 HEDIS® NCQA Quality Measures Update for Pneumococcal Vaccination

Pneumococcal vaccination status for older adults17,a

For 2019, NCQA defined the pneumococcal immunization status as members 66 years of age and older as of the start of the measurement period, minus exclusions, who were administered both the 13-valent pneumococcal conjugate vaccine and the 23-valent pneumococcal polysaccharide vaccine at least 12 months apart, with the first occurrence after the age of 60; or prior pneumococcal vaccine adverse reaction any time during or before the measurement period.

  1. aPneumococcal vaccination history will determine the use of each vaccine in this patient population. Please see CDC Sequential Dosing Recommendation Guide.

HEDIS®=Healthcare Effectiveness Data and Information Set. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

CDC=Centers for Disease Control and Prevention.

Commercial Insurance

Commercial insurance may provide coverage for employed adult patients aged 19 to 64 years.

Some vaccinating pharmacies may be able to adjudicate commercial medical claims for vaccinations.

  • When the pharmacy is signed up with the relevant medical insurer to process medical claims or when the claim can be processed through a PBM
  • Vaccines reimbursed under a medical benefit are usually provided at an in-network physician’s office

Consult private insurer or public program for reimbursement details.

Remember: The reimbursement-related information in this resource is general in nature. This information is subject to change. It is not intended to be exhaustive, nor to replace the guidance of a qualified reimbursement advisor, and does not constitute legal or reimbursement advice. The use of the information presented here is not a guarantee of coverage or payment. As a provider, you are solely responsible for billing payers correctly and for determining whether any payer-specific guidelines apply. Merck does not guarantee or ensure the timeliness or appropriateness of this information for your particular use given the frequent changes in public and private payer billing.

PBM=pharmacy benefit manager.

ref16

Reference

  1. Centers for Medicare & Medicaid Services. Modifications to Medicare Part B coverage of pneumococcal vaccinations. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9051.pdf. Accessed November 13, 2019.
ref17

Reference

  1. National Committee for Quality Assurance (NCQA). HEDIS® 2019 Volume 2 Technical Update. https://www.ncqa.org/wp-content/uploads/2018/10/HEDIS-2019-Volume-2-Technical-Update.pdf. Accessed November 15, 2019.

Indication for PNEUMOVAX 23

PNEUMOVAX® 23 (Pneumococcal Vaccine Polyvalent) is a vaccine indicated for active immunization for the prevention of pneumococcal disease caused by the 23 serotypes contained in the vaccine (1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, and 33F).

PNEUMOVAX 23 is approved for use in persons 50 years of age or older and persons aged ≥2 years who are at increased risk for pneumococcal disease.

PNEUMOVAX 23 will not prevent disease caused by capsular types of pneumococcus other than those contained in the vaccine.

Do not administer PNEUMOVAX 23 to individuals with a history of a hypersensitivity reaction to any component of the vaccine.
Defer vaccination with PNEUMOVAX 23 in persons with moderate or severe acute illness.

Do not administer PNEUMOVAX® 23 (Pneumococcal Vaccine Polyvalent) to individuals with a history of a hypersensitivity reaction to any component of the vaccine.

Defer vaccination with PNEUMOVAX 23 in persons with moderate or severe acute illness.

Use caution and appropriate care in administering PNEUMOVAX 23 to individuals with severely compromised cardiovascular and/or pulmonary function in whom a systemic reaction would pose a significant risk.

Available human data from clinical trials of PNEUMOVAX 23 in pregnancy have not established the presence or absence of a vaccine-associated risk.

Since elderly individuals may not tolerate medical interventions as well as younger individuals, a higher frequency and/or a greater severity of reactions in some older individuals cannot be ruled out.

Persons who are immunocompromised, including persons receiving immunosuppressive therapy, may have a diminished immune response to PNEUMOVAX 23.

PNEUMOVAX 23 may not be effective in preventing pneumococcal meningitis in patients who have chronic cerebrospinal fluid (CSF) leakage resulting from congenital lesions, skull fractures, or neurosurgical procedures.

The most common adverse reactions, reported in >10% of subjects vaccinated with PNEUMOVAX 23 in clinical trials, were: injection-site pain/soreness/tenderness, injection-site swelling/induration, headache, injection-site erythema, asthenia and fatigue, and myalgia.

For subjects aged 65 years or older in a clinical study, systemic adverse reactions which were determined by the investigator to be vaccine-related were higher following revaccination than following initial vaccination.

Vaccination with PNEUMOVAX 23 may not offer 100% protection from pneumococcal infection.

Before administering PNEUMOVAX 23, please read the accompanying Prescribing Information. The Patient Information also is available.

PNEUMOVAX® 23 (Pneumococcal Vaccine Polyvalent) is a vaccine indicated for active immunization for the prevention of pneumococcal disease caused by the 23 serotypes contained in the vaccine (1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, and 33F).

PNEUMOVAX 23 is approved for use in persons 50 years of age or older and persons aged ≥2 years who are at increased risk for pneumococcal disease.

PNEUMOVAX 23 will not prevent disease caused by capsular types of pneumococcus other than those contained in the vaccine.


US-PNX-00807 02/20