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The purpose of this bulletin is to inform providers that all Center for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP)-recommended RSV vaccines and monoclonal antibody preventive therapies will be covered for all full-benefit DMAS fee-for-service (FFS) and managed care organization (MCO) members.

Adults at least 60 Years of Age

In light of recent FDA approval of RSV vaccine products for individuals at least 60 years of age, claims for the following RSV vaccine product codes with dates of service on and after 6/21/2023, that are consistent with ACIP recommendations, will be covered for FFS and MCO members at least 60 years of age:

• 90678: Respiratory syncytial virus vaccine, preF, subunit, bivalent, for intramuscular use

• 90679: Respiratory syncytial virus vaccine, preF, recombinant, subunit, adjuvanted, for intramuscular use

Pregnant Individuals Between 32-36 Weeks Gestation 

In light of recent FDA approval of an RSV vaccine product for pregnant individuals between 32-36 weeks gestation, claims for the following RSV vaccine product code with dates of service on and after 9/22/2023, that are consistent with ACIP recommendations, will be covered for FFS and MCO pregnant members:

• 90678: Respiratory syncytial virus vaccine, preF, subunit, bivalent, for intramuscular use

Providers administering vaccines to Vaccines for Children (VFC)-eligible pregnant members (i.e., full benefit members under 19 years of age) will receive an administrative fee for billing the corresponding vaccine product code as per Chapter V of the DMAS Practitioner Manual. 

Infants & Children Under 19 Months of Age

In light of recent FDA approval of an RSV monoclonal antibody product for infants, claims for the following RSV vaccine product codes with dates of service on and after 8/3/2023, that are consistent with ACIP recommendations (one dose for all infants younger than 8 months born during, or entering, their first RSV season, and a second dose for children 8 to 19 months of age who are at increased risk of severe RSV disease in their second season), will be covered for FFS and MCO pediatric members:

• 90380: Respiratory syncytial virus, monoclonal antibody, seasonal dose; 0.5 mL dosage, for intramuscular use

• 90381: Respiratory syncytial virus, monoclonal antibody, seasonal dose; 1 mL dosage, for intramuscular use

DMAS currently covers 96372, which is appropriate to bill in conjunction with administration of the aforementioned RSV monoclonal antibody products. Vaccine administration codes are not appropriate to bill with monoclonal antibody products. Providers administering monoclonal antibody products to VFC-eligible members will receive up to the amount reimbursed by 96372, when billed in conjunction with the monoclonal antibody product code, for their administrative efforts.

Additional billing instructions for vaccines billed under the medical benefit for FFS members is available in Chapters IV and V of the Practitioner Manual here. Inpatient facilities would bill all injections and/or immunizations under a 0250 revenue code, with payment included in the DRG when administering an RSV monoclonal antibody product to inpatient infants.

FFS and MCO adult members over 60 years of age may receive RSV vaccines from pharmacy providers. Claims should be submitted via the point-of-sale pharmacy claims system. An administration fee of $11 will be paid for the service. A dispensing fee will not be paid.

Any questions on FFS pharmacy claims processing may be directed to the Magellan pharmacy call center 7 days a week 24 hours per day at 800-932-6648.

For questions on medical or pharmacy coverage for members enrolled in a managed care organization, refer to the contact information listed below.