OBJECTIVES: Czech guidelines recommend 23-valent pneumococcal polysaccharide vaccination (PPSV23) for people living in homes for the elderly, long-term hospitals, homes for the disabled and special-regime homes (the last two were excluded for lack of valid data, assuming that wouldn’t influence results since they make only a negligible part of vaccinated people). A 13-valent pneumococcal conjugate vaccine (PCV13) has had significant public-health impacts in children and is currently being evaluated for use in adults in the Czech Republic (CR). The objective of this study was to assess the cost-effectiveness of pneumococcal vaccination strategies in the elderly population. METHODS: A first-order Markov decision-analytic model was developed to compare cost-effectiveness of vaccination with PCV13, PPSV23 and no vaccination in the Czech Republic.  PPSV23 effectiveness was derived from literature and PCV13 was extrapolated from impact in children adjusting for immunosenescence in older persons.  Pneumonia, bacteremia and meningitis hospitalization and cost data were acquired from health authorities and DRG system in CR; outpatient data were based on retrospective patient survey.  The model used a lifetime time horizon and 3% discount rate. RESULTS: Used according to Czech guidelines, PCV13 vaccination is associated with 0.0002 life-years gained for an additional EUR 1.002 on average (EUR 3,812,478 in total) compared to no vaccination and 0.0004 life-years gained for additional EUR 0.97 on average (EUR 3,704,061 in total) compared to PPSV23. This leads to an ICER of EUR/LYG 4,950 and 2,265 under current reimbursement. If all moderate and high risk people were vaccinated, the ICER would increase to EUR/LYG 5,582 and 6,691, respectively, under current reimbursement and to ICER of EUR/LYG 8,676 and 7,057 under full reimbursement. CONCLUSIONS: Confronting the national GDP per capita with the WHO recommendation on health care spending per QALY gained, PCV13 national immunization program in the Czech Republic can be considered cost-effective even under a full reimbursement policy.