Respiratory Syncytial Virus (RSV) is a prevalent respiratory virus that typically causes mild cold-like symptoms in adults and older children. However, it can be more severe, particularly in infants and young children. The necessity for RSV vaccination or prophylaxis arises from the potential for more severe and life-threatening RSV infections in vulnerable populations, especially infants with underdeveloped immune systems or underlying health issues.

Types of vaccines:

  1. Abrysvo and Arexvy: a single dose of RSV vaccine for individuals aged 60 and above, using shared clinical decision-making. It can be billed as a medical or pharmacy point-of-sale (POS) claim.
  2. Abrysvo for maternal indications: ACIP recommends maternal RSV vaccination for pregnant individuals during 32-36 weeks gestation,. Billing can be done as a medical or pharmacy POS claim for those aged 19 and above.
  3. Beyfortus: Nirsevimab-alip is available through the Vaccines for Children (VFC) Program. Recommended for infants less than 8 months old entering their first RSV season and for those 8 to 19 months at increased risk entering their second RSV season.
  4. Synagis: Coverage is from Nov. 1, 2023, to March 31, 2024. It is covered at pharmacy POS with prior authorization required, and not through the Physician-Administered Drug Program (PADP).

5. Counseling Coverage:For children 0 to 20 months, code 99401 can be used for counseling on Monoclonal Antibody use for RSV prevention during the 2023-2024 RSV season

Abrysvo-(HCPCS code 90678)

The RSV vaccine is recommended to actively immunize individuals aged 60 and older, aiming to prevent lower respiratory tract disease (LRTD) caused by RSV. Additionally, it is advised as a maternal RSV vaccine for pregnant individuals between 32-36 weeks gestation, administered seasonally, to prevent RSV lower respiratory tract infections in infants.

Recommended Dose: The recommended dose for Abrysvo administration is a single approximately 0.5 mL dose.

Covered Ages for Abrysvo:

  • Effective July 17, 2023, Abrysvo is covered for beneficiaries 60 years of age and older in both pharmacy and medical claims.
  • Effective Sept. 22, 2023, Abrysvo is covered for beneficiaries from 0 years of age and older for PADP claims and for 19 years of age and older for pharmacy claims.

Arexvy-(HCPCS code 90679)

This vaccine is recommended for active immunization to prevent lower respiratory tract disease (LRTD) caused by RSV in individuals aged 60 and older. Supplied as a single-dose vial of lyophilized antigen component, intended for reconstitution with the accompanying adjuvant suspension component. The reconstituted solution results in a single 0.5 mL dose.

Recommended Dose: Administer a single dose (0.5 mL) as an intramuscular injection.

Synagis- (HCPCS 90378)

1.    Eligibility for First RSV Season Prophylaxis (Up to 12 Months):

  • Premature infants born before 29 weeks 0 days gestation.
  • Infants with Chronic Lung Disease (CLD) of prematurity (birth at less than 32 weeks 0 days gestation and requiring oxygen for at least 28 days after birth).
  • Infants with hemodynamically significant acyanotic heart disease, pulmonary hypertension, neuromuscular disease, cystic fibrosis, or other conditions impairing upper airway secretion clearance.
  • Cyanotic heart disease infants may receive prophylaxis with cardiologist recommendation.

2.    Eligibility for Second RSV Season Prophylaxis (Up to 24 Months):

  • CLD of prematurity requiring ongoing medical support during the six-month period before the start of the second RSV season.
  • Cystic Fibrosis with severe lung disease or nutritional compromise.

3.    Prophylaxis During First or Second RSV Season for Certain Conditions:

  • Profound immunocompromise.
  • Infants undergoing cardiac transplantation during the RSV season.

4.    Coverage Limitations:

  • Coverage for CLD, profound immunocompromise, cardiac transplantation, and cystic fibrosis terminates when the beneficiary exceeds 24 months of age.
  • Discontinuation of Synagis coverage if an infant or child on monthly palivizumab prophylaxis experiences a breakthrough RSV hospitalization due to the extremely low likelihood of a second same-season hospitalization (<0.5%).

Beyfortus – (HCPCS code 90380 / HCPCS Code 90381)

HCPCS code 90380: RSV, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use

Coverage: 49281-0575-15

HCPCS Code 90381: RSV, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use

Coverage: 49281-0574-15

Counseling Code 99401

For the new RSV monoclonal antibody product, Beyfortus, Medicaid allows providers to use CPT code 99401 for counseling beneficiaries about its benefits. This service can be provided in person, through telehealth, or telephonically, with no quantity limits per beneficiary per day.

Covered Ages: The counseling can be billed by multiple providers and on different days, but it’s restricted to beneficiaries aged 0-20 months during the 2023-2024 RSV season.

In conclusion, the objective is to minimize the risk of severe respiratory illnesses, hospitalizations, and complications associated with RSV in these high-risk groups. The effectiveness of a vaccine is typically assessed through clinical trials and real-world studies, examining factors such as the prevention of infections, severity of illness, and overall impact on public health.

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