In infants, young children and older adults, respiratory syncytial virus (RSV) can cause severe lower respiratory tract diseases such as bronchiolitis and pneumonia, as well as asthma, COPD and heart failure exacerbations.
With the increase in RSV activity across the United States, the Centers for Disease Control and Prevention (CDC) has recommended the 2023-2024 RSV immunization for higher risk populations. Those at risk include:
- Adults aged 60 and over.
- People who are 32-36 weeks.
- Infants and young children.
Previously, the Alliance has shared information about prevention of RSV in infants and young children with the use of Synagis and Beyfortus. This is a follow-up to provide additional guidance for RSV vaccination in adults, and related details for authorization and billing.
Arexvy and Abrysvo
There are two vaccines for use: Arexvy and Abrysvo. See the table below for recommendations for use and dosing.
Both vaccines are recombinant protein vaccines that cause the immune system to produce antibodies against RSV. Arexvy contains an adjuvant meant to enhance the immune response to the vaccine.
The CDC does not have a preferential recommendation for either vaccine for adults aged 60 years and older. Adults 60 years and older should talk with their health care provider about whether RSV vaccination is right for them. Adults with weakened immune systems, including those receiving medicines that suppress the immune system, may have a reduced immune response.
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Recommendations for use of RSV vaccines |
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RSVPreF3 (Arexvy)
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RSVpreF (Abrysvo)
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Dosing |
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Both Arexvy and Abrysvo vaccines are administered as a single dose (0.5 mL) intramuscularly.
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Vaccines for Children (VFC) program
Abrysvo may be available through the VFC program for enrolled providers to administer to pregnant individuals through 18 years of age.
The California Department of Public Health (CDPH) welcomes California providers to join the VFC program if they are:
- Birthing hospitals, acute care hospitals and others providing care to neonatal patients.
- Serving minors who are Medi-Cal eligible, American Indian/Alaskan Native, uninsured and underinsured.
Alliance authorization and billing for RSV vaccines billed as a medical claim using an HCPCS/CPT code or “buy and bill”
Please note: There is a delay in DHCS updates on RSV vaccines. All claims are being pended until DHCS provides an update. Updated billing instructions will be shared once available.
Prior authorization will not be required for Arexvy and Abrysvo if administered according to Food and Drug Administration (FDA) approval and recommendation by the Center for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP). If deviating from FDA approval or ACIP recommendation, please submit a prior authorization request via the Alliance Provider Portal or by fax to 831-430-5851.
To bill the Alliance for administration of VFC-supplied vaccine doses, use the appropriate CPT-4 code, followed by the “-SL” modifier. Providers will only be reimbursed for the administration fee when using VFC vaccines for members.
| Vaccine | CPT Code | Available As |
| Arexvy | 90679 |
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| Abrysvo | 90678-SL |
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Medi-Cal Rx coverage for RSV vaccines billed as a pharmacy claim
Both Arexvy and Abrysvo are covered at the pharmacy without prior authorization by Medi-Cal Rx if the vaccine is used following CDC guidelines.
Prescriptions that are filled at a pharmacy are covered by Medi-Cal Rx instead of the Alliance. For more information on billing and prior authorization requests, go to the Medi-Cal Rx website.
Thank you for caring for our members. If you have any questions, please call the Alliance Pharmacy Department at 831-430-5507.
