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Elizabeth M. Whitehorn, Director

Provider Notice issued 12/20/2024

 

To:  Enrolled Physicians; Advanced Practice Nurses: Physician Assistants; Local Health Departments; Hospitals; Federally Qualified Health Centers; Rural Health Clinics; Encounter Rate Clinics; and Pharmacies
​Date December 20, 2024
​Re:
 Abrysvo™ (Respiratory Syncytial Virus Vaccine) - Seasonal Update

This notice confirms to providers coverage of the Abrysvo vaccine for pregnant customers under specified circumstances, and adults aged 60 years and over.

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. Based on guidance from the U.S. Centers for Disease Control and Prevention (CDC) (Immunizations to Protect Infants | RSV | CDC) and The American College of Obstetricians and Gynecologists (ACOG) (Maternal Respiratory Syncytial Virus Vaccination | ACOG), Abrysvo coverage during pregnancy is available seasonally, from September through January. Providers should expect these same coverage requirements on a yearly basis, unless otherwise notified by HFS.

Abrysvo is available via medical billing without a prior authorization. It 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 year-round 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 FFS claims, or the appropriate MCO.                                                   

                                 

Kelly Cunningham, Administrator
Division of Medical Programs