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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsBaylor Scott & White Beyfortus Auth | OpenPayer
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    CurrentBaylor Scott & White Health PlanPolicy 305

    Nirsevimab-alip (Beyfortus) for RSV prevention

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    This policy governs medical necessity and prior authorization for nirsevimab-alip (Beyfortus) to prevent RSV lower respiratory tract disease in eligible infants and young children during RSV season.

    Policy Summary
    PayerBaylor Scott & White Health Plan
    PolicyNirsevimab-alip (Beyfortus) for RSV prevention
    Policy CodePolicy 305
    Change TypeMaterial revision
    Effective DateOct 1, 2026
    Last ReviewSep 24, 2026
    Next Review DateSep 24, 2027
    Key ActionSubmit prior authorization and confirm CDC/ACIP eligibility and fewer than five palivizumab doses in the current RSV season.
    SourceLink
    POLICY UPDATE CHANGES

    Coverage may be allowed when the pregnant parent did not receive RSVpreF vaccination during the current pregnancy.

    Background and references were updated.

    2Covered CPT codes
    RequiredAuthorization status

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    <8 months
    First-season age group
    8-19 monthsSecond-season high-risk age group
    <5 dosesPalivizumab dose limit

    Nirsevimab Eligibility

    Coverage limitation: Members with five or more palivizumab (Synagis®) doses during the current RSV season do not meet nirsevimab eligibility criteria.

    Coding and Dose Parameters

    CPT CodesCPTCovered
    90380Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use
    90381Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use
    HCPCS CodesHCPCS
    No codes listed
    ICD-10 CodesICD-10
    No codes listed
    ICD-10 Not CoveredICD-10Not Covered
    No codes listed
    Prior Palivizumab Doses
    Eligibility thresholdFewer than 5 palivizumab (Synagis) doses in the current RSV season
    Eligible dose range0–4 palivizumab doses during the current RSV season
    Exclusion threshold5 or more palivizumab doses during the current RSV season

    Authorization and Denial Risks

    Prior Authorization

    Obtain prior authorization before administration

    Prior authorization is required for nirsevimab-alip (Beyfortus). Submit documentation showing that the member meets a CDC/ACIP eligibility pathway and has received fewer than five palivizumab doses during the current RSV season.

    Denial Risk

    Confirm CDC/ACIP eligibility

    Coverage may be denied if the member does not meet one of the CDC/ACIP eligibility pathways for the first or second RSV season, or does not qualify for an additional dose after cardiac surgery with cardiopulmonary bypass.

    • First RSV season: younger than 8 months and born during or entering the first RSV season with a qualifying risk or maternal vaccination condition.
    • Second RSV season: 8 to 19 months, entering the second RSV season, and at increased risk for severe RSV disease.
    • Cardiac surgery: undergoing cardiac surgery with cardiopulmonary bypass during or entering the first or second RSV season and eligible for an additional post-surgery dose.

    Clinical Background

    Nirsevimab-alip (Beyfortus) is a respiratory syncytial virus (RSV) F protein-directed fusion inhibitor monoclonal antibody indicated to reduce RSV lower respiratory tract disease in eligible infants and young children during the RSV season. Eligibility is based on CDC and ACIP immunization recommendations, with additional guidance from the American Academy of Pediatrics regarding nirsevimab and palivizumab.

    Initial Therapy Requirements

    Initial Nirsevimab Therapy

    Initial therapy is covered when both the CDC/ACIP eligibility requirement and the palivizumab exposure requirement are met.

    Initial therapy requirements

    • CDC/ACIP pathway: The member is younger than 8 months entering the first RSV season with a qualifying condition; is 8 to 19 months entering the second RSV season with increased risk for severe RSV disease; or is undergoing cardiac surgery with cardiopulmonary bypass during or entering the first or second RSV season and needs an additional post-surgery dose.
    • Palivizumab requirement: The member has received fewer than five palivizumab doses during the current RSV season.<5 doses
    Policy Summary
    PayerBaylor Scott & White Health Plan
    PolicyNirsevimab-alip (Beyfortus) for RSV prevention
    Policy CodePolicy 305
    Change TypeMaterial revision
    Effective DateOct 1, 2026
    Last ReviewSep 24, 2026
    Next Review DateSep 24, 2027
    Key ActionSubmit prior authorization and confirm CDC/ACIP eligibility and fewer than five palivizumab doses in the current RSV season.
    SourceLink
    On This Page
    Nirsevimab EligibilityCoding and Dose ParametersAuthorization and Denial RisksClinical BackgroundInitial Therapy Requirements
    Denial Risk

    Verify palivizumab dose count

    Coverage may be denied if the member has received five or more doses of palivizumab (Synagis) during the current RSV season. Confirm the current-season dose count before requesting nirsevimab-alip.

    • The member must have received fewer than five palivizumab doses in the current RSV season.