RSV, or Respiratory Syncytial Virus, is a common winter virus that can cause infants and young children to develop wheezing, fevers, and difficulty breathing. Each year in the US, RSV leads to over 2 million doctor visits and 50,000 hospitalizations of children (and more in older adult populations). There is typically no treatment for RSV and babies sick enough to be hospitalized often need oxygen until their immune system is able to fight off the virus.
You may have heard, there is an injectable medicine available to prevent severe RSV illness in infants. This medication gives immunity against the virus, but is not technically a vaccine. As a monoclonal antibody, this medicine gives infection-fighting power to the body directly, by giving antibodies through the shot (which is different from vaccines, which turn on your body's own antibody making power). Babies from birth to 8 months old (and some older babies with chronic health conditions) are eligible for this medication, which can reduce the risk of illness requiring hospitalization from RSV by up to 80%! Safety profiles of the medication in the trials were excellent, showing only local reactions to the skin. If an expectant mom receives an adult RSV vaccine prior to delivery, the baby will not likely need this injection.
Please note that there are now two products on the market for infants, Beyfortus and Enflonsia. The administration rules for both products are the same for younger babies (less than 8 months of age). Hilliard Pediatrics will be administering Enflonsia this season. We are typically only able to administer Enflonsia from October 1st through March 31st each season. Enflonsia can be given at a regularly scheduled appointment or schedule a nurse visit if you don't have any questions for the provider. Enflonsia is not able to be given at our COVID and flu vaccine clinics.
So what now?
- Well, first call, your insurance company. See how much or IF they might cover Enflonsia for your newborn or infant under 8 months of age. If they won't cover it, ask them why not and ask them to change their policy.
- Additionally, if not covered, we recommend reaching out to your HR department to get them to fight on your behalf as well.
- When you call you insurance, they may ask you for CPT codes and possibly a diagnosis code.
- CPT Code - 90382
- Diagnosis Code - for injection of Enflonsia, the ICD-10 code is Z29.11.
- Secondly, if you have a baby this fall, ask the birth hospital if they are giving this medication to babies before leaving the hospital. You can also ask your OB about the adult vaccine before delivery. As long as the vaccine was administered at least 2 weeks before delivery, baby does not need to receive Beyfortus or Enflonsia.
- Third, Call the health department as they might be able to provide some doses of Beyfortus or Enflonsia at a lower cost, especially to the under-insured populations.
As a newer medication, most, but not all insurance companies are covering this medication. We will use shared decision making to give this medication to infants who qualify but will unfortunately need families to understand that some or all costs might fall on their shoulders. The good news is that we had very few claims last year that resulted in out-of-pocket costs for parents so we are optimistic that coverage will be good. While we wish the potential financial and insurance obstacles weren't an issue, we are excited about the excellent prevention this shot can offer.
For more information about RSV or Enflonsia, check out the following sites: