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Elizabeth M. Whitehorn, Director

Provider Notice issued 10/14/2025

 

To:
 Enrolled Physicians, Advanced Practice Nurses, Nurses, Physician Assistants, Local Health Departments, Hospitals, Federally Qualified Health Centers, Rural Health Clinics, Encounter Rate Clinics, Pharmacies, and Early Intervention Services
​Date October 14, 2025
​Re:
 Upcoming Respiratory Syncytial Viral (RSV) Season

This notice serves to inform providers of the Department of Healthcare and Family Services’ (HFS) policies on the billing of RSV immunizations during the upcoming season. This notice is applicable for both Medicaid fee-for-service (FFS) and Managed Care Organizations (MCOs).

The Department will be approving RSV drugs Beyfortus (nirsevimab) or Enflonsia (clesrovimab) for infants as follows:

  • First RSV season, <8 months of age

  • Beyfortus (nirsevimab) OR Enflonsia (clesrovimab) is recommended by the American Academy of Pediatrics (AAP) and the Advisory Committee on Immunization Practices (ACIP) for RSV prevention in this patient. 

  • Second RSV season between 8 months and 19 months of age

  • Beyfortus (nirsevimab) is recommended by the American Academy of Pediatrics (AAP) and the Advisory Committee on Immunization Practices (ACIP) for RSV prevention in this patient. 

Enflonsia and Beyfortus are both recommended to be given during the first week of life, preferably before discharge, for infants born during the RSV season. Palivizumab (SYNAGIS) is a short-acting monoclonal antibody product that is administered in monthly doses during the RSV season. Palivizumab is no longer routinely recommended for use and will be discontinued as of December 31, 2025. 

The Department will be approving Abrysvo for pregnant adults according to the following guidelines:

  • Pregnant Adult RSV Recommendations

  • Currently, only the RSV vaccine Abrysvo is FDA-approved for pregnant women during weeks 32 through 36 of pregnancy. Current criteria for approval include gestational verification of 32 0/7 through 36 6/7 weeks gestation, and that administration will take place during the months of September through January per guidance from the American College of Obstetricians and Gynecologists (ACOG). 

For Adult RSV vaccinations Abyrsvo, mResvia, and Arexvy will be covered in patients age 50 and older.

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565, or the applicable MCO.

 

Laura Phelan
Division of Medical Programs