CurrentAvMedPolicy N/A

Abrysvo (RSV vaccine) for Active Immunization of Pregnancy — Prior Authorization and Coverage Criteria

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.

Policy Summary

PayerAvMed

PolicyAbrysvo (RSV vaccine) for Active Immunization of Pregnancy — Prior Authorization and Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a completed AvMed medical prior authorization form with prescriber hand signature and all supporting documentation; fax to 1-877-535-1391.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

32w0d–36w6dgestational age window for coverage

1drug specifically named

1office-administered prior auth

Coverage Criteria

Coverage criteria — gestational window

Covered when ALL of the following are met

Gestational age and documentation: Member is pregnant and is between 32 weeks, 0 days and 36 weeks, 6 days gestational age32w0d-36w6d

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

Requested: Diagnosis/ICDICD-10

ICD Code, if applicable (field present on form)

Provider Actions & Authorization Requirements

Policy Summary

PayerAvMed

PolicyAbrysvo (RSV vaccine) for Active Immunization of Pregnancy — Prior Authorization and Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit a completed AvMed medical prior authorization form with prescriber hand signature and all supporting documentation; fax to 1-877-535-1391.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior Authorization

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.

Step Therapy

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.

Documentation Required

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).

Denial Risk

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

Coverage at zero-dollar cost share — key facts

DefinitionCoverage provided without member cost-share when the listed clinical criteria are met.

Applicable clinical criterionMember is pregnant and is between 32 weeks, 0 days and 36 weeks, 6 days gestational age.

Documentation requirementAll documentation, including lab results, diagnostics, and chart notes, must be provided for each checked criterion or request may be denied.

Form fields that support determinationDiagnosis and ICD code (if applicable), dosing schedule, length of therapy, weight and date obtained, drug name/form/strength.