CurrentCareFirstPolicy N/A

Respiratory Syncytial Virus (RSV) Vaccines for Adults

Defines medical necessity and coverage criteria for RSV vaccines (Abrysvo, Arexvy, mRESVIA) in adults and for Abrysvo in pregnancy, for CareFirst-managed benefits.

Policy Summary

PayerCareFirst

PolicyRespiratory Syncytial Virus (RSV) Vaccines for Adults

Policy CodePolicy N/A

Change TypeAdoption of FDA approvalsclarified ACIP differences

Effective DateFeb 1, 2026

Next Review Date

Key ActionSubmit preauthorization requests online or by phone when prior authorization is required per member contract.

SourceLink

POLICY UPDATE CHANGES

Policy updated to adopt FDA approvals for Abrysvo and mRESVIA in high-risk adults aged 18-74, and to remove mRESVIA from the experimental/investigational designation.

ACIP updated recommended age of adults at increased risk from 60-74 to 50-74, but the policy adheres to FDA-approved age ranges for certain vaccines.

3vaccines addressed (Abrysvo, Arexvy, mRESVIA)

≥75age group universally recommended in policy

18-74FDA approvals adopted for high-risk individuals

32-36 wksAbrysvo pregnancy window covered

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Coverage Criteria for RSV Vaccines

Arexvy coverage

Covered when ALL of the following are met

Arexvy criteria: Adults aged 75 years and older OR adults aged 50-74 years at increased risk of severe RSV diseaseage and risk-based

CareFirst adopts ACIP/FDA age stratification for Arexvy as stated in policy guidelines

Abrysvo coverage (adults and pregnancy)

Covered when ALL of the following are met

Abrysvo adults: Adults aged 75 years and older OR adults aged 18-74 years at increased risk of severe RSV diseaseage and risk-based

CareFirst adopts FDA approvals for Abrysvo including high-risk adults 18-74

Abrysvo pregnancy: Pregnant persons during 32 through 36 weeks gestational age (third trimester) during RSV season for prevention of infant RSV lower respiratory tract disease (LRTD)gestational age 32-36 weeks

Prescribing information includes warning about potential preterm birth if given outside 32-36 weeks

mRESVIA coverage

Covered when ALL of the following are met

mRESVIA adults: Adults aged 75 years and older OR adults aged 18-74 years at increased risk of severe RSV diseaseage and risk-based

Policy adopts FDA approval extending use in high-risk adults age 18-74; CareFirst follows FDA approvals

Experimental / Investigational

Not covered (experimental/investigational) when ANY of the following apply

Unapproved indications: Use of Abrysvo and Arexvy for indications outside the Policy Guidelines is considered experimental/investigational and is not covereddoes not meet BCBSA/TEC criteria

mRESVIA was removed from the experimental/investigational designation per the 2025 update; Abrysvo and Arexvy remain experimental/investigational for other unapproved indications

Abrysvo and Arexvy are considered experimental/investigational for any indication that does not meet the policy’s stated medical criteria and guidelines. CareFirst applies the BCBSA/TEC-derived assessment criteria: a technology must meet all required evidentiary and regulatory standards (including final U.S. regulatory approval and sufficient evidence of improved net health outcomes) to be considered medically necessary. Use of Abrysvo or Arexvy outside the policy guideline indications therefore does not meet those criteria and is not covered.

Vaccination with Abrysvo or Arexvy outside the established age groups or, for Abrysvo in pregnancy, outside the specified gestational window is considered not medically necessary because safety and effectiveness have not been established. The prescribing information and available trial data do not support use in younger adults excluded from clinical trials or in pregnant persons outside the 32 through 36 weeks gestational age window; therefore such administration will not be covered.

Billing and Coding

Provider Actions and Authorization

Prior Authorization

Prior authorization may be required

Some services, drugs, and places of service require prior authorization—providers must check the member's contract for benefits and submit preauthorization requests when required.

Verify member-specific benefits and prior authorization requirements in the member contract before scheduling or administering RSV vaccines.

Step Therapy

Step therapy

No step therapy requirements are specified in this policy for Abrysvo, Arexvy, or mRESVIA.

Documentation Required

Preauthorization and submission

Background

Respiratory syncytial virus (RSV) is an RNA virus that causes seasonal respiratory infections and can progress to serious lower respiratory tract disease such as bronchiolitis and pneumonia. Infants, older adults, and immunocompromised persons are at higher risk for severe disease; severe RSV may require hospitalization and supportive care including oxygen, intravenous fluids, or mechanical ventilation. Vaccination with licensed RSV vaccines (Arexvy, Abrysvo, and mRESVIA) is intended to reduce the incidence of RSV lower respiratory tract disease in older adults and selected high‑risk younger adults.

Definitions

Lower respiratory tract disease (LRTD) — definition and clinical significance

DefinitionLower respiratory tract disease (LRTD): serious RSV-related lung infections such as bronchiolitis (inflammation of the small airways) and pneumonia that can require hospitalization and advanced respiratory support (oxygen, IV fluids, intubation, or mechanical ventilation).

Clinical signsMay present with cough, wheezing, shortness of breath, decreased appetite, fever, runny nose; can progress to respiratory failure in severe cases.

At-risk populationsInfants, young children, older adults, and immunocompromised adults are at increased risk for LRTD and RSV-related mortality.

Severity implicationsHospitalization may be required for dehydration, hypoxia, or respiratory distress; advanced support may include oxygen therapy and mechanical ventilation.

Public health relevanceRSV causes seasonal epidemics (peaking in winter in temperate climates) and is an important cause of LRTD and death in infants and older adults.

Policy Summary

PayerCareFirst

PolicyRespiratory Syncytial Virus (RSV) Vaccines for Adults

Policy CodePolicy N/A

Change TypeAdoption of FDA approvalsclarified ACIP differences

Effective DateFeb 1, 2026

Next Review Date

Key ActionSubmit preauthorization requests online or by phone when prior authorization is required per member contract.

SourceLink

On This Page

Submit preauthorization requests online at www.provider.carefirst.com or by calling CareFirst at 1-866-773-2884 (1-866-PRE-AUTH); always verify member contract provisions as they supersede policy criteria.

Use the online portal (www.provider.carefirst.com) or phone (1-866-773-2884) for preauthorization submission.
Confirm any contract-specific restrictions or exclusions before submitting, since member contract terms take precedence.

Denial Risk

Denial risk for unapproved indications

Use of Abrysvo and Arexvy for indications outside the policy guidelines is considered experimental/investigational and may be denied.

Vaccination outside the established age groups or pregnancy window where safety and efficacy have not been established is considered not medically necessary and may be denied.

High‑risk for severe RSV — definition and criteria used in policy (including FDA-applied age ranges)

Definition used in policyHigh‑risk for severe RSV: individuals with conditions or factors that increase risk of severe RSV disease as applied by FDA approvals and CareFirst policy.

Age ranges applied by CareFirst (FDA-adopted)Adults aged 18–74 years when identified as at increased risk for severe RSV (CareFirst adopts FDA approvals for Abrysvo and mRESVIA in high‑risk adults 18–74).

Arexvy age criteriaAdults aged ≥75 years, or adults aged 50–74 years at increased risk of severe RSV disease (per Arexvy criteria in policy).

Abrysvo age and pregnancy criteriaAdults aged ≥75 years, or adults aged 18–74 years at increased risk of severe RSV disease; pregnant persons during 32–36 weeks gestational age for prevention of infant RSV LRTD.

mRESVIA age criteriaAdults aged ≥75 years, or adults aged 18–74 years at increased risk of severe RSV disease (policy adopts FDA approval for high‑risk adults).