Sept. 1, 2023

RSV Vaccine Coverage Update
Applies to all non-grandfathered groups

Beginning Sept. 1, 2023, we will cover the Respiratory Syncytial Virus (RSV) vaccine without cost sharing for adults, as recommended by the Advisory Committee on Immunization Practices (ACIP).

What you need to know:

• This year, the Food and Drug Administration (FDA) approved two new RSV vaccines, Abrysvo and Arexvy, for the prevention of lower respiratory tract disease caused by RSV in those age 60 and older.

• We will cover both RSV vaccines without cost sharing when obtained at a doctor’s office (as a medical claim) or at a participating pharmacy (as a pharmacy claim) for groups that have Prime^® Therapeutics as their Pharmacy Benefits Manager (PBM).
• IL HMO members must get the vaccines at an in-network provider to have it covered without cost sharing.
  

• Groups that have carved-out pharmacy benefits should check with their PBM to confirm their coverage and implementation of this update.

• As with any preventive service, the vaccine must be obtained from an in-network provider to be covered without cost sharing.

• This coverage update is effective Sept. 1, regardless of renewal date for all non-grandfathered ACA-compliant plans.

Note: The RSV vaccine for infants (Beyfortus) is a different drug and is covered under the medical plan only.

Blue Cross and Blue Shield of Illinois (BCBSIL) contracts with Prime Therapeutics to provide pharmacy benefit management and related other services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics. MyPrime.com  is an online resource offered by Prime Therapeutics.