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Provider Notice issued 12/08/2023
| Date: | December 8, 2023 |
| To: | Enrolled Physicians; Advanced Practice Nurses: Physician Assistants; Local Health Departments; Hospitals; Federally Qualified Health Centers; Rural Health Clinics; Encounter Rate Clinics; and Pharmacies |
| Re: | Abrysvo RSV Vaccine for Pregnant Illinois Medicaid Customers |
This notice services to inform providers that the Department of Healthcare and Family Services (HFS) covers the Respiratory Syncytial Virus (RSV) vaccine, Abrysvo, for pregnant Illinois Medicaid customers with a gestational age of 32 weeks through 36 weeks. It is available via medical billing without a prior authorization. Abrysvo is also available through pharmacy billing with a physician-submitted prior authorization for pregnant customers with the same gestational age requirements.
Prescribing providers will be required to document the gestational age at the time of Abrysvo administration in the pregnant customer’s medical records and obtain an informed consent signed by the patient, informing the pregnant patient of the potential benefits to the newborn baby, and potential adverse risks to current pregnancy (pre-eclampsia and pre-term birth reported in clinical trials of Abrysvo). It remains the responsibility of the prescriber to document in the patient’s medical record and communicate the date of the mother’s vaccination with Abrysvo, with both the pediatrician assigned to care for the newborn baby as well as the birthing center or birthing hospital. The prescribing provider’s medical records will be subject to audit by HFS.
Pregnant customers under the age of 19 can only receive Abrysvo via the Vaccines for Children (VFC) Program.
Abrysvo is also available for Illinois Medicaid customers aged 60 and over through the pharmacy point-of-sale and medical billing without a prior authorization.
Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565 for fee-for-service claims, or the appropriate MCO.
Kelly Cunningham, Administrator
Division of Medical Programs