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California Health & Wellness is no longer a Medi-Cal plan starting January 1, 2024. Regardless of the county you live in, your Medi-Cal service and benefits will not be impacted by the health plan changes since you will be assigned to a new health plan. The county you live in determines your new health plan. Learn more

23-1467 Protect Your Adult Patients and Patients Who Are Pregnant Against RSV Illness

Date: 12/21/23

Help patients access RSV vaccines to avoid severe respiratory illness this winter

Respiratory syncytial virus (RSV) is a common respiratory virus that typically causes mild, cold-like symptoms. Most people recover within two weeks. However, older adults are susceptible to developing severe infections including bronchiolitis (an inflammation of the small airways in the lung) and pneumococcal pneumonia. Also, individuals who are pregnant and receive the RSV vaccine can help protect their newborns from serious RSV illness.

Use the guidance below to help determine which RSV vaccines are available to your patients and their coverage.

Symptoms of infection

Symptoms of RSV infection may include runny nose, decrease in appetite, coughing, sneezing, fever, or wheezing. RSV can also worsen serious health conditions, including asthma, chronic obstructive pulmonary disease (COPD) and congestive heart failure.

Who should get an RSV vaccine?

  • Pregnant women during weeks 32 through 36 of pregnancy (prior authorization is required).
  • Adults ages 60 and older, especially if they have chronic medical conditions such as heart or lung disease, weakened immune systems, or certain other underlying medical conditions, or who live in nursing homes or long-term care facilities. No prior authorization is required.

Available vaccines

The U.S. Food and Drug Administration has approved certain immunizations that can reduce the risk of RSV-related complications and hospitalizations. The vaccines listed below are covered under the Affordable Care Act as a preventive care vaccine at no out-of-pocket cost for members.

Vaccine

Description

Arexvy (RSVPreF3) and Abrysvo (RSVpreF)

Approved for adults age 60 and older. These vaccines contain a part of the RSV and work by causing an immune response that can protect you from respiratory disease if you are infected with RSV in the future.

Abrysvo (RSVpreF)

Recommended for use during pregnancy. It is given during RSV season to people who are 32 through 36 weeks in order to protect infants from severe complications related to RSV.

Vaccine access and coverage

CHWP members can receive the RSV vaccine through the retail pharmacies they access for their prescriptions.

Claim submission for vaccines

Reimbursement for the vaccines is in accordance with the terms of the provider’s Provider Participation Agreement and the member’s benefit plan design.

Additional information

Providers are encouraged to access CHWP’s provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.

 

This information applies to Physicians, Independent Practice Associations (IPAs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.