ModifiedmeridianPolicy MDN.CP.PHAR.658

Respiratory syncytial virus vaccine (Abrysvo, Arexvy, mResvia)

Customize your policy alerts

Sign up for meridian Policy MDN.CP.PHAR.658 alerts

Get alerted when Policy MDN.CP.PHAR.658 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines medical necessity and coverage criteria for Abrysvo, Arexvy, and mResvia immunizations for Meridian Illinois Medicaid pharmacy benefits, including initial approval criteria, contraindications, dosing, and documentation expectations.

Policy Summary

Payermeridian

PolicyRespiratory syncytial virus vaccine (Abrysvo, Arexvy, mResvia)

Policy CodePolicy MDN.CP.PHAR.658

Change TypeAdded Arexvy & mResviaRSV season dates extended

Effective DateFeb 1, 2024

Last ReviewFeb 27, 2026

Next Review DateFeb 27, 2026

Key ActionSubmit pharmacy prior authorization with documentation showing the member meets the specified approval criteria; dose limited to one 0.5 mL injection.

SourceLink

POLICY UPDATE CHANGES

Arexvy was added to the policy.

mResvia was added to the policy.

RSV season dates were updated/extended per State of Illinois provider notices.

3vaccines covered

one-timedose limit

32–36 wksgestational window

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.

ModifiedmeridianPolicy MDN.CP.PHAR.658

Respiratory syncytial virus vaccine (Abrysvo, Arexvy, mResvia)

Customize your policy alerts

Sign up for meridian Policy MDN.CP.PHAR.658 alerts

Get alerted when Policy MDN.CP.PHAR.658 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

Payermeridian

PolicyRespiratory syncytial virus vaccine (Abrysvo, Arexvy, mResvia)

Policy CodePolicy MDN.CP.PHAR.658

Change TypeAdded Arexvy & mResviaRSV season dates extended

Effective DateFeb 1, 2024

Last ReviewFeb 27, 2026

Next Review DateFeb 27, 2026

Key ActionSubmit pharmacy prior authorization with documentation showing the member meets the specified approval criteria; dose limited to one 0.5 mL injection.

SourceLink

POLICY UPDATE CHANGES

Arexvy was added to the policy.

mResvia was added to the policy.

RSV season dates were updated/extended per State of Illinois provider notices.

3vaccines covered

one-timedose limit

32–36 wksgestational window

Sept–Janseasonal months

Coverage Criteria

Initial Therapy — Abrysvo

Covered when ALL of the following are met for the specified vaccine:

Abrysvo - adult or pregnant: Member meets one of: (a) Age \u2265 18 years; OR (b) Pregnant and meets BOTH: i. pregnant at 32 through 36 weeks gestation; ii. administration occurs during the months September through January (State of Illinois extended season through March 31, 2026)

Dose does not exceed one injection (0.5 mL) given one time; approval duration: 1 month

Initial Therapy — Arexvy and mResvia

Covered when ALL of the following are met for Arexvy and mResvia:

Arexvy and mResvia: Member is age \u2265 50 years

Dose does not exceed one injection (0.5 mL) given one time; approval duration: 1 month

Non–FDA approved indications that are not specifically addressed in this clinical policy are not authorized for coverage unless the provider submits sufficient documentation demonstrating efficacy and safety in accordance with applicable off‑label use policies (for Medicaid, see CP.PMN.53) or other evidence of coverage documents. Providers requesting coverage for off‑label use must include supporting clinical documentation such as office chart notes, relevant test results, and any other information that substantiates the medical necessity of the proposed use.

For Medicaid members, if there is a conflict between this clinical policy and state Medicaid coverage provisions, the state Medicaid coverage provisions take precedence. Providers should consult the applicable state Medicaid manual and provider notices for any specific coverage rules or updates that supersede this policy.

Initial Therapy

Initial therapy — pharmacy benefits one-time dosing criteria

Initial approval criteria for pharmacy benefits (one-time dosing):

Dose limit: One injection (0.5 mL) given one time; single-dose vial 0.5 mL after reconstitution0.5 mL/one-time dose

Approval duration: 1 month; administration route: intramuscular

Coding and Billing

CPT vaccine codes referencedCPT

90678	Respiratory Syncytial Virus vaccine, preF, subunit, bivalent, for intramuscular use.
90679	Respiratory Syncytial Virus vaccine, preF, subunit, bivalent, for intramuscular use.
90683	Respiratory syncytial virus vaccine, mRNA lipid nanoparticles, for intramuscular use.

Coding — N/A

Coding thresholdsN/A

NoteInclusion or exclusion of codes does not guarantee coverage; reference current coding guidance prior to claim submission.

CPT codes referenced90678, 90679, 90683

Provider Actions and Requirements

Prior Authorization

Prior authorization required — meet approval criteria and dosing limit

Pharmacy benefit requests require documentation that the member meets all approval criteria; dose is limited to one 0.5 mL injection given one time. Submit supporting clinical information demonstrating the member meets the Initial Approval Criteria for the specific vaccine requested.

Dose limit: one injection (0.5 mL) given one time.
Approval duration: 1 month.

Prior Authorization

Prior authorization / coding note — revision history aligned with state notices

Policy revision history documents additions and updates tied to State of Illinois provider notices (Arexvy and mResvia added; RSV season dates updated). Specific prior authorization procedures are not detailed in this section — follow state alignment noted in the revision history when applicable.

Arexvy was added to the policy (9.19.24 revision).
mResvia was added to the policy and updates made per 10/14/25 and 11/20/25 Illinois provider notices; RSV season later extended per 2/27/26 notice.

Background

Respiratory syncytial virus (RSV) is a common cause of lower respiratory tract disease (LRTD), particularly affecting infants and older adults. Maternal immunization with Abrysvo during late pregnancy is intended to provide transplacental antibodies to protect infants through approximately the first 6 months of life. Current guidance supports administering maternal Abrysvo as a one‑time intramuscular dose administered in the gestational window of 32 0/7 to 36 6/7 weeks, timed to local RSV seasonality.

For older adults, RSV vaccines (including Arexvy and mResvia) are used to prevent RSV‑associated LRTD in indicated age groups; product labeling and advisory guidance define age thresholds (e.g., typically ≥50 or ≥60 years) and the vaccines are dosed as a single intramuscular injection of 0.5 mL given one time. This policy aligns product indications, ACIP/CDC recommendations, and state guidance to establish coverage criteria and the one‑time dose limit.

Definitions

LRTD definition

DefinitionAdministration timed to local RSV seasonality (generally September through January in most of the continental United States).

Illinois extensionState of Illinois extended season through March 31, 2026 for maternal vaccination timing.

Local guidanceJurisdictions with different seasonality should follow state, local, or territorial guidance.

Seasonal administration

DefinitionAdministration timed to local RSV seasonality (generally September through January in most of the continental United States).

Pregnancy timingMaternal Abrysvo recommended as a one-time dose at 32 0/7 to 36 6/7 weeks' gestation using seasonal administration.

Quantity Limits and Dosing

Abrysvo / Arexvy / mResvia — dose limit 0.5 mL

ProductsAbrysvo, Arexvy, mResvia dose limit

Dose limitOne injection (0.5 mL) given one time; single-dose vial 0.5 mL after reconstitution.

Approval durationApproval duration: 1 month (one-time dose).

Site of Care and Formulation

Step Therapy

Office administration — single-dose vial 0.5 mL; IM one-time dose

Single-dose vial is 0.5 mL after reconstitution; administer as a one-time intramuscular injection in the office setting.

Quantity limit: one 0.5 mL injection per course.
Site of care: office (intramuscular administration).

Policy Summary

Payermeridian

PolicyRespiratory syncytial virus vaccine (Abrysvo, Arexvy, mResvia)

Policy CodePolicy MDN.CP.PHAR.658

Change TypeAdded Arexvy & mResviaRSV season dates extended

Effective DateFeb 1, 2024

Last ReviewFeb 27, 2026

Next Review DateFeb 27, 2026

Key ActionSubmit pharmacy prior authorization with documentation showing the member meets the specified approval criteria; dose limited to one 0.5 mL injection.

SourceLink

On This Page

Note

Include supporting clinical documentation with authorization requests

Providers must include documentation that the member meets the coverage criteria when submitting pharmacy benefit authorization requests; lack of required documentation may prevent approval.

Include office chart notes, lab results, attestation, or other clinical information as applicable.

Denial Risk

Verify eligibility details on requests to avoid denial

Confirm the requested vaccine, patient age or pregnancy gestational window, seasonal timing, and single‑dose quantity on the prior authorization; discrepancies between request and criteria (age, gestation, season, dose) risk denial.

Abrysvo: age ≥18 OR pregnant at 32–36 weeks and administered during September–January (Illinois season extended through March 31, 2026).
Arexvy and mResvia: age ≥50 years.
Dose must not exceed one injection (0.5 mL) given one time.

Documentation Required

Required documentation — submit clinical evidence of criteria met

Provider must submit documentation (office chart notes, lab results, attestation, or other clinical information) supporting that the member has met all approval criteria to obtain authorization.

Documentation should directly reference the approval criteria (age/gestation, seasonal timing, and dose).

Billing Rule

Coding guidance required — use current professional coding sources

Providers should reference the most up-to-date professional coding guidance prior to claim submission; codes listed in this policy are informational and do not replace current coding resources.

Verify CPT and billing guidance before claim submission to ensure accurate coding and reimbursement.

Denial Risk

Denial risk — missing supporting documentation

Failure to submit required supporting documentation (office chart notes, lab results, attestation, or other clinical information) demonstrating the member meets all approval criteria may trigger denial of the authorization request.

Ensure documentation explicitly supports age, pregnancy gestational window (if applicable), seasonal administration, and dosing limits.

Note

Coding inclusion informational — listed codes do not guarantee coverage

Codes included in the policy (e.g., 90678, 90679, 90683) are provided for informational purposes only; inclusion or exclusion does not guarantee coverage and providers must follow current coding guidance when billing.

90678, 90679, 90683 are listed in the policy coding implications section but do not by themselves authorize coverage.

Local exceptionsFollow state, local, or territorial guidance where RSV seasonality differs from most of the continental U.S.

respiratory syncytial virus (RSV)

TermRespiratory syncytial virus (RSV)

AbbreviationRSV

Clinical relevanceCauses lower respiratory tract disease, particularly in infants and older adults; prevention is the purpose of referenced vaccines.

lower respiratory tract disease (LRTD)

TermLower respiratory tract disease (LRTD)

DefinitionLower respiratory tract disease caused by RSV as referenced in vaccine indications.

Associated riskRSV-associated LRTD prevention is the covered indication for the vaccines in this policy.