23-1466 Protect Your Adult Patients and Patients Who Are Pregnant Against RSV Illness
Date: 12/21/23
Help patients access RSV vaccines to avoid severe respiratory illness this winter
Respiratory syncytial virus (RSV) is a common respiratory virus that typically causes mild, cold-like symptoms. Most people recover within two weeks. However, older adults are susceptible to developing severe infections including bronchiolitis (an inflammation of the small airways in the lung) and pneumococcal pneumonia. Also, individuals who are pregnant and receive the RSV vaccine can help protect their newborns from serious RSV illness.
Use the guidance below to help determine which RSV vaccines are available to your patients and their coverage.
Symptoms of infection
Symptoms of RSV infection may include runny nose, decrease in appetite, coughing, sneezing, fever, or wheezing. RSV can also worsen serious health conditions, including asthma, chronic obstructive pulmonary disease (COPD) and congestive heart failure.
Who should get an RSV vaccine?
- Pregnant women during weeks 32 through 36 of pregnancy (prior authorization is required).
- Adults ages 60 and older, especially if they have chronic medical conditions such as heart or lung disease, weakened immune systems, or certain other underlying medical conditions, or who live in nursing homes or long-term care facilities. No prior authorization is required.
Available vaccines
The U.S. Food and Drug Administration has approved certain immunizations that can reduce the risk of RSV-related complications and hospitalizations. The following are covered under the Affordable Care Act as a preventive care vaccine at no out-of-pocket cost for members.
Vaccine | Description |
|---|---|
Arexvy (RSVPreF3) and Abrysvo (RSVpreF) | Approved for adults age 60 and older. These vaccines contain a part of the RSV and work by causing an immune response that can protect you from respiratory disease if you are infected with RSV in the future. |
Abrysvo (RSVpreF) | Recommended for use during pregnancy. It is given during RSV season to people who are 32 through 36 weeks in order to protect infants from severe complications related to RSV. |
Vaccine access and coverage
- Commercial (IFP, HMO, EPO, PPO, POS, HSP) – for Health Net only
Commercial and Marketplace adult members, ages 60 and older, and those who are pregnant, can receive the RSV immunization from their primary care physician or can go to a local pharmacy.
Participating physician groups (PPGs) with financial responsibility: Refer to the Division of Financial Responsibility (DOFR) in your Provider Participation Agreement to confirm financial responsibility for adult immunizations. If the PPG does not have the RSV vaccine available or is unable to obtain the vaccine, refer members to a local pharmacy to receive their RSV immunization. The cost of the immunization will be deducted from the PPG’s capitation payment at Health Net’s actual cost.
- Medi-Cal
Medi-Cal members can receive the RSV vaccine through the retail pharmacies they access for their prescriptions.
- Medicare – applies to Wellcare By Health Net and Wellcare
Medicare members can receive the RSV vaccine through the retail pharmacies they access for their prescriptions. The RSV vaccines are covered under Medicare Part D prescription drug coverage.
Claim submission for vaccines
Reimbursement for the vaccines is in accordance with the terms of the provider’s Provider Participation Agreement and the member’s benefit plan design.
Additional information
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email, by telephone or through the Health Net provider portal.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.