New RSV vaccine and monoclonal antibody coverage
As we approach the 2023 RSV season, we’re aligning with the CDC’s Advisory Committee on Immunization Practices (ACIP) recommendation to cover the new Arexvy and Abrysvo vaccines as well as the new Beyfortus monoclonal antibody treatment under our members’ preventive benefit.
Priority Health members have access to these treatments at $0 cost as follows:
| Code | Description | HMO/EPO, POS, PPO |
Medicaid /Healthy Michigan Plan | Medicare Advantage plans |
| 90679 | Arexvy vaccine. 1 dose per year. Age limit: 60 years old or older |
YES | YES | NO Covered under Medicare Part D |
| 90678 |
Abrysvo vaccine.1 dose per year. Age limit: 60 years old or older or pregnant women. |
YES | YES | NO Covered under Medicare Part D |
| 90380 | Beyfortus monoclonal antibody. 1 dose per year. Ages 0-24 months. |
YES Prior authorization is required for patients over 8 months of age. |
NO (adults) VFC (children) |
YES Prior authorization required. |
| 90381 | Beyfortus monoclonal antibody. 1 dose per year. Ages 0-24 months. |
YES Prior authorization is required for patients over 8 months of age. |
NO (adults) VFC (children) |
YES Prior authorization required. |
How are these codes covered?
These are covered under our members’ preventive benefit at $0 cost. Like other preventive services, coverage through out-of-network providers depends on a member’s plan. All are covered under our members’ medical benefit, except for Arexvy and Abrysvo for Medicare members which are covered under Medicare Part D.
Prior authorization requirement for Beyfortus
Prior authorization is required for monoclonal antibody treatment, Beyfortus, for commercial members over the age of 8 months and for MA members. Providers should use our drug request forms to request prior authorization, like our existing process for Synagis.
Recommended timing for Beyfortus
Providers should administer Beyfortus to infants < 8 months old and to infants and children 8–19 months old who’re at increased risk for severe RSV disease beginning shortly before the start of the RSV season.