Recommended Does Not Automatically Mean Covered

A vaccination recommendation is a medical assessment; insurance coverage is a legal matter. The Federal Commission for Vaccination (FCV) and the Federal Office of Public Health (FOPH) assess who would benefit from a vaccine. Whether compulsory health insurance pays for it, however, is determined by the Federal Department of Home Affairs through the Health Insurance Benefits Ordinance (KLV).

Since January 1, 2026, Article 12a KLV has referred to a separate reference document, Prophylactic Vaccinations, rather than the Swiss vaccination schedule. This document provides an exhaustive list of the indications and vaccination schedules covered by basic health insurance. For coverage to apply, three conditions must all be met:

• The indication is listed in the reference document for Article 12a KLV.
• The vaccine is included in the List of Pharmaceutical Specialties (SL) for the relevant age group and indication, subject to any coverage restrictions.
• Swissmedic has approved the vaccine for that indication, which is a prerequisite for inclusion in the SL.

This means a vaccine may be recommended without being covered—for example, because it has not been approved for a particular age group (an “off-label” recommendation) or because a reimbursement decision is still pending. Until recently, this discrepancy affected pneumococcal vaccination for some risk groups. It remains an issue for RSV vaccination in adults.

Two additional rules apply to all vaccinations covered under Article 12a KLV:

• No deductible: Since January 1, 2026, these vaccinations and the associated vaccination counseling have been exempt from the annual deductible. The 10% co-pay still applies.
• No coverage for travel or occupational indications: Anyone receiving a vaccine for travel or work-related reasons must pay out of pocket, even if the same vaccine is covered for other groups.

Pneumococcal Disease: Risk Peaks at Both Ends of Life

Pneumococci (Streptococcus pneumoniae) are bacteria that many people carry in their nose and throat without knowing it. However, they can cause middle ear infections and pneumonia, as well as life-threatening invasive infections such as meningitis and sepsis. There are more than 100 pneumococcal types, known as serotypes. Vaccines cover those most commonly responsible for severe disease.

The risk of disease has two peaks. Children under 5, especially infants, become ill significantly more often than older children. Older adults, however, are affected most severely: According to impfen-schweiz.ch, around 500 older adults develop invasive pneumococcal disease each year, and approximately 60 die from it. Around 8,500 older adults are hospitalized annually with pneumococcal pneumonia. In healthy people aged 5–64, by contrast, infections are generally mild and severe disease is very rare.

The recommendations reflect this pattern: routine vaccination for all infants, supplementary vaccination for everyone aged 65 and older and vaccination in between for those at an increased risk, for example due to a chronic condition or a weakened immune system.

Pneumococcal Vaccination: Who Should Get Vaccinated?

The FCV and FOPH recommend a pneumococcal conjugate vaccine (PCV) for all target groups. The number in the vaccine’s name indicates how many serotypes it protects against. The FCV summarized its vaccine recommendations for each group in its statement dated July 1, 2026.

The recommendation for at-risk adults aged 18–64 is new: Since July 1, 2026, PCV21 is the only vaccine recommended for this group because it is the only one both approved and covered. PCV20 is now used only as an off-label alternative during supply shortages. PCV15 is no longer recommended for adults because it covers significantly fewer of the serotypes currently circulating.

Risk factors include severe heart or lung disease, liver cirrhosis, absence of a spleen, advanced kidney disease, diabetes with organ damage, cancer undergoing treatment, transplantation, HIV, and treatment with immunosuppressive medication.

Already Vaccinated?

Adults who previously received PCV13 or PCV15 can receive a single additional dose of a vaccine covering more serotypes, no earlier than one year after their last dose, or after six months in exceptional cases. For people aged 65 and older, this means one dose of PCV20 or PCV21 after PCV13, or one dose of PCV21 after PCV15. At-risk adults aged 18–64 receive PCV21. Anyone who has already received PCV20 does not currently need another dose. Routine boosters are not recommended.

Pneumococcal Vaccination: When Does Health Insurance Pay?

Coverage for pneumococcal vaccination now largely aligns with the recommendations. According to the reference document dated July 1, 2026, basic health insurance covers:

• Infants and young children: The routine three-dose series and catch-up vaccination through age 4. A four-dose schedule is covered for preterm infants born before 32 weeks of pregnancy or weighing less than 1,500 g and for children with a risk factor. Otherwise, it is not covered.
• Everyone aged 65 and older: A single dose of a PCV covering as many serotypes as possible. An additional dose is also covered for people aged 65 and older who received PCV13 or PCV15 between January 1, 2023, and December 31, 2025.
• At-risk individuals aged 5 and younger or 18 and older: Vaccination for the underlying conditions listed in the reference document. Since July 1, 2026, PCV21 (Capvaxive®) has been covered for adults aged 18–64 with a risk factor, subject to the restrictions specified in the SL.

At-risk children and adolescents aged 6–17, however, must pay out of pocket. Although the FCV and FOPH recommend PCV15 or PCV20 for them, no vaccine is approved for this age group. The indication is therefore absent from the reference document, which explicitly provides coverage only through age 5 and from age 18 onward. Vaccination is also not covered for healthy people aged 5–64, for whom it is also not recommended.

The reference document does not explicitly list an additional PCV21 dose for at-risk adults aged 18–64 who previously received PCV13 or PCV15. In these cases, it is worth checking coverage with your health insurer beforehand.

RSV: A Cold Virus with Serious Consequences Early and Late in Life

During the colder months, RSV is the most common reason infants need hospital care. The virus spreads through droplets, aerosols, and hands. It is so contagious that virtually all children have been infected at least once by their third birthday. Infection does not produce lasting immunity, so people can catch it repeatedly. In Switzerland, the RSV season usually runs from November through March, peaking in January and February.

In adolescents and healthy adults, RSV usually feels like a common cold. In infants, however, the infection can spread to the smallest airways, which are still very narrow, causing bronchiolitis. According to the FOPH bulletin published in September 2026, 2.4% of all infants were hospitalized with RSV each year before the pandemic. In the 2022/23 season, this figure rose to 3.7%. Babies in their second month of life are most at risk. Notably, more than 80% of hospitalized infants are healthy babies born at term.

The risk rises again later in life. Among people aged 75 and older, the hospitalization rate is almost four times that of 65- to 74-year-olds. The FOPH estimates around 2,800 RSV-related hospitalizations annually in this age group, with an average stay of approximately 10 days. Because adults are rarely tested for RSV, its disease burden has long been underestimated. Younger adults with certain underlying conditions or a weakened immune system can also become seriously ill.

RSV in Infants: Vaccination During Pregnancy or Antibodies

All infants should be protected during their first RSV season, either through maternal vaccination during pregnancy or an antibody given after birth. The FCV and FOPH consider both approaches equally valid. Combining them is recommended only in specific situations.

Maternal Vaccination

Pregnant women aged 18 and older should receive one dose of Abrysvo® between 32 weeks, 0 days and 36 weeks, 0 days of pregnanc, but only if their due date falls between the beginning of October and the end of March. The mother’s antibodies cross the placenta and protect the baby from birth. Vaccination should take place at least 14 days, and ideally five weeks, before delivery. Currently, only one maternal dose is recommended. In the event of a subsequent pregnancy, the newborn should receive the antibody instead.

Monoclonal Antibodies

In addition to nirsevimab (Beyfortus®), a second long-acting antibody, clesrovimab (Enflonsia®), has been available since 2026. This is a form of passive immunization: The child is protected immediately after administration. Timing depends on the month of birth:

• Born October–March: One dose during the first week of life, ideally while still in the maternity unit, provided the mother was not vaccinated.
• Born April–September: One dose in October before the first RSV season, or as soon as possible afterward.
• Children up to 24 months of age at high risk: A second dose of nirsevimab in October before their second RSV season. Risk factors include severe heart or lung disease, birth before 32 weeks of pregnancy, a weakened immune system and Down syndrome.

Even if the mother was vaccinated, the newborn receives an antibody if birth occurs less than 14 days after vaccination or before 37 weeks of pregnancy, if the mother is immunosuppressed or if the child has certain serious medical conditions.

Insurance Coverage

Basic health insurance covers maternal vaccination, both antibodies, and their administration—including in the maternity unit—as well as the second dose for high-risk children. Vaccination during pregnancy is covered only between 32 weeks, 0 days and 36 weeks, 0 days, and only when the due date falls between October and March. Antibody administration after March 31 is not covered for healthy infants born between October and March who missed the recommended timing.

RSV in Adults: Newly Recommended from Age 18, but Not Covered

For adults, the gap between recommendations and insurance coverage is currently greatest. The three RSV vaccines Abrysvo®, Arexvy®, and mResvia® are now approved from age 18. The FCV and FOPH updated their recommendations accordingly in 2026. A single dose is recommended for:

• Everyone aged 75 and older as a supplementary vaccination, unchanged from 2025.
• Adults aged 65–74 at high risk, for example those with heart failure of NYHA class II or higher, a history of heart attack, COPD of GOLD grade 2 or higher, asthma requiring ongoing treatment, stage 4 or higher kidney disease, diabetes with organ damage, cancer undergoing treatment, or immunosuppression, as well as those who are frail or live in a nursing home.
• Adults aged 18–64 at very high risk: This is a new, narrowly defined group, including people with heart failure of NYHA class III or higher, GOLD grade 3 COPD, leukemia or lymphoma, a transplant, intensive immunosuppression, or HIV with a low CD4 count.

The ideal time for vaccination is mid-October to mid-November, before the RSV wave begins. It can be given at the same time as a flu or COVID-19 vaccine. Based on current knowledge, one dose provides protection for at least three years. Whether and when a booster will be needed remains unclear. All three vaccines can be used, with no preference for a particular product.

Insurance Coverage

None. The reference document explicitly excludes RSV vaccination for adults, regardless of age or risk factors. The only exception is vaccination during pregnancy to protect the newborn. This means that an 80-year-old or a 40-year-old transplant recipient who receives the vaccine must pay for both the vaccine and its administration out of pocket. According to the FOPH, potential reimbursement is under review as of fall 2026. Some supplementary insurance plans contribute toward vaccination costs, so it may be worth contacting your insurer.

At a Glance: Recommendations and Coverage

What This Means for You

Recommendations for pneumococcal and RSV protection in infants and adults aged 65 and older are clearly established but a gap between recommendations and reimbursement remains for adults at risk of RSV. Parents should plan their baby’s RSV protection during pregnancy, because timing and the month of birth matter. Older adults and people with chronic conditions should have their pneumococcal vaccination status reviewed in the fall, especially if they previously received PCV13 or PCV15. Adults considering RSV vaccination should be aware that it may be medically beneficial but currently requires out of pocket payment.

A vaccination consultation is the best way to determine which vaccine makes sense for your individual situation and whether your health insurance covers it. Counseling for vaccinations covered by basic health insurance is also exempt from the annual deductible.