Abrysvo (RSV vaccine) for Active Immunization of Pregnancy — Prior Authorization and Coverage Criteria
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Defines prior authorization and clinical criteria for covering Abrysvo (RSV vaccine) during pregnancy for AvMed members; applies to providers requesting medical (office-administered) coverage. Affects pregnant members and prescribers submitting PA requests.
No material clinical or coverage changes in this revision.
Coverage Criteria
Coverage criteria — gestational window
Covered when ALL of the following are met
All documentation including lab results, diagnostics, and chart notes must be provided for each checked criterion
Use of samples to initiate therapy does not meet preauthorization or step-edit criteria. Previous therapies will be verified through pharmacy paid claims or submitted chart notes; providers should not rely on sample use as evidence of prior treatment when submitting a prior authorization request.
Requested Diagnosis / Coding
| ICD Code, if applicable (field present on form) |
Provider Actions & Authorization Requirements
Prior authorization required — submit AvMed medical PA form
Abrysvo (RSV Vaccine) for Active Immunization of Pregnancy requires prior authorization. Submit the AvMed medical prior authorization/step-edit request form with the prescriber signature and complete information; fax to 1-877-535-1391.
Samples and prior therapy verification
Use of samples to initiate therapy does not satisfy step-edit or preauthorization requirements; the plan will verify previous therapies through pharmacy paid claims or submitted chart notes.
Required form fields and supporting documentation
Provide all required form fields and supporting documentation: a hand-signed prescriber signature (preprinted stamps not valid), member and prescriber details, drug name/form/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), weight and date obtained, and supporting documentation for each checked clinical criterion (labs, diagnostics, chart notes).
Missing or incomplete documentation may delay or deny authorization
Authorization may be delayed or denied if information is incomplete, incorrect, or illegible; requests may be denied if supporting documentation for each checked clinical criterion is not provided.
Background
Abrysvo is an RSV vaccine indicated for active immunization of pregnant persons intended to provide passive protection to the infant. AvMed requires prior authorization for office-administered (medical) use and expects documentation on the medical PA form to support administration during the specified gestational window, including all relevant lab results, diagnostics, and chart notes.
Definitions
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