Skip to Main Content
Ready to renew your Medicaid coverage? Explore our step-by-step guide to Medicaid renewal. Here's how
Ready to renew your Medicaid coverage? Explore our step-by-step guide to Medicaid renewal. Here's how

Respiratory Syncytial Virus (RSV) Vaccine Updates

Date: 11/14/24

Respiratory syncytial virus (RSV) usually causes mild, cold-like symptoms but may be especially serious for young children and older adults. It is the most common cause of hospitalization in U.S. infants.1

Please see the table below for RSV vaccine guidance.

An administration fee is only available for Beyfortus™ if the provider is enrolled in the Vaccine for Children (VFC) program as indicated in the October 30, 2024, provider notice from the Illinois Department of Healthcare and Family Services (HFS).

Drug Name

Indications

Prior Authorization (PA)

Claim Types

Abrysvo™

  • Prevention of lower respiratory tract disease (LRTD) caused by respiratory syncytial virus (RSV) in people 60 years of age and older
  • Pregnant individuals at 32 through 36 weeks gestational age for the prevention of LRTD and severe LRTD caused by RSV in infants from birth through 6 months of age

PA for pregnant individuals when applying Pharmacy Benefits; PA not required for medical billing

Pharmacy or Medical

Arexvy®

  • Prevention of LRTD caused by RSV in individuals 60 years of age and older
  • Individuals 50 through 59 years of age who are at increased risk for LRTD caused by RSV

Preferred

Pharmacy or Medical

Beyfortus™

  • Prevention of serious lung disease caused by RSV in newborns and babies under 1 year of age born during or entering their first RSV season
  • Children up to 24 months of age who remain at risk of severe RSV disease through their second RSV season

Non-preferred

Medical – Hospital or Provider Offices

Administration fee available only for Beyfortus obtained through the Vaccine for Children (VFC) program5

 

Synagis®

  • Prevention of serious lower respiratory tract disease caused by RSV in pediatric patients with the following indications:
    • Children with a history of premature birth (≤35 weeks gestational age) and who are 6 months of age or younger at the beginning of RSV season
    • Children with bronchopulmonary dysplasia (BPD) that required medical treatment within the previous 6 months and who are 24 months of age or younger at the beginning of RSV season
    • Children with hemodynamically significant congenital heart disease (CHD) and who are 24 months of age or younger at the beginning of RSV season

Non-preferred

Medical – Hospital or Provider Offices

Pharmacy or Medical

 

 

References

  1. CDC Respiratory Syncytial Virus (RSV) Vaccine Information Sheet. Accessed November 13, 2024.
  2. Abrysvo. Accessed November 13, 2024.
  3. Arexvy. Accessed November 13, 2024.
  4. Beyfortus. Accessed November 13, 2024.
  5. Respiratory Syncytial Virus (RSV) Prevention: Beyfortus and Synagis. Illinois Department of Healthcare and Family Services provider notice issued October 30, 2024. Accessed November 13, 2024.
  6. Synagis. Accessed November 13, 2024.