Medicaid Makes Prevnar-13 Payment Retroactive to March 18

Ohio Medicaid is backdating coverage of Prevnar 13 to March 18, the date on which the vaccine became available through Ohio's Vaccines for Children Program (VFC).

Claims submitted between the dates of March 18 and May 1 may be resubmitted for payment. This decision follows a meeting that OAFP and Ohio Chapter of American Academy of Pediatrics had with Medicaid on July 13 relative to the gap is appropriate payment for Prevnar-13 during the shift from the older vaccine Prevnar-7 with the VFC program.

Ohio Department of Health Immunization Program announced on March 22 that Prevnar-13 was available for ordering through the VFC program effective March 18 but reimbursement for the new Prevnar-13 was not enacted until May 1.

Physician offices were experiencing the financial burden of covering the cost of providing the new vaccine within the VFC program at the reimbursement rate of the old vaccine for a period of six weeks.

Prevnar-13 (the 13-Valent Pneumococcal Conjugate Vaccine) contains polysaccharides of the capsular antigens of Streptococcus pneumoniae serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F and 23F. PCV-13 is approved for use among children aged six weeks though 71 months and will replace PCV-7.

ODJFS will also be informing its Medicaid managed care plans of this decision.