NC Medicaid is providing guidance on the 2024-2025 Respiratory Syncytial Virus (RSV) season for NC Medicaid Direct and NC Managed Care health plans and is based on products approved by the Food and Drug Administration (FDA) and recommended by the Center for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP). For details on the 2024-2025 recommendations, please refer to CDC RSV ACIP Vaccine Recommendations.

The North Carolina Division of Public Health has set the RSV season to start on September 15, 2024, for the 2024-2025 RSV season. Please refer to the North Carolina Immunization Branch (NCIP) Memos and Communication webpage and NC Department of Health and Human Services Division of Public Health Provider Memos for Respiratory Illnesses and NC Communicable Diseases Manual for pertinent updates to the RSV season dates from the State of North Carolina.

Summary of NC Medicaid RSV Coverage

  • Abrysvo™, Arexvy, and mRESVIATM: ACIP recommends adults 75 years of age and older receive a single dose of RSV vaccine. ACIP recommends adults 60–74 years of age and older who are at increased risk of severe RSV disease receive a single dose of RSV vaccine. It is available to bill as a medical or pharmacy point-of-sale (POS) claim.
  • Abrysvo™ for maternal indications: ACIP recommends a maternal RSV vaccine for pregnant people during 32-36 weeks gestation, using seasonal administration, to prevent RSV lower respiratory tract infections in infants. Abrysvo is available to bill as a medical or pharmacy POS claim; pharmacy point-of-sale claims can only be billed for beneficiaries greater than or equal to 19 years of age. Please refer to Clinical Coverage Policy 1E-5 Obstetrical Services for additional coverage information. Abrysvo is available through VFC program to VFC providers for beneficiaries less than 19 years of age. Providers should follow ACIP recommendations to administer Abrysvo.
  • Beyfortus™: Nirsevimab-alip is available through the VFC program to VFC providers. ACIP recommends nirsevimab for all infants less than 8 months of age who are born during or entering their first RSV season and for infants and children 8 to 19 months of age who are at increased risk for severe RSV disease and are entering their second RSV season. For additional information about these recommendations see Use of Nirsevimab for the Prevention of Respiratory Syncytial Virus Disease Among Infants and Young Children: Recommendations of the Advisory Committee on Immunization Practices — United States, 2023.
  • Synagis®: Coverage starts Sept. 15, 2024, and ends March 31, 2025. Covered at pharmacy POS and prior authorization (PA) is required; Synagis® is not covered through the Physician-Administered Drug Program (PADP).
    The clinical criteria used by NC Medicaid for the 2024/2025 RSV season are consistent with guidance published by the American Academy of Pediatrics (AAP): 2024 – 2027 Report of the Committee on Infectious Diseases, 33rd Edition. This guidance for Synagis use among infants and children at increased risk of hospitalization for RSV infection is available online by subscription. Providers are encouraged to review the AAP guidance.

Continue reading the full bulletin released by NC Medicaid here.