MaineCare 2024-25 Respiratory Syncytial Virus (RSV) Update

Oct 21, 2024

Peak RSV activity typically occurs between October and March. Please find information below regarding MaineCare’s coverage of nirsevimab (Beyfortus™) and palivizumab (Synagis®) 

Nirsevimab 

• Available to all eligible MaineCare members through the Maine Immunization Program and Vaccine for Children Program at medical practices and birth hospitals. Nirsevimab is not covered by MaineCare.  

• Recommended for infants ages birth to 8 months from October 1, 2024, to March 31, 2025, and high-risk infants, ages 8 months to 19 months per CDC guidance. 

Palivizumab 

• Available for eligible high-risk infants ages birth to 24 months for whom nirsevimab is not indicated or if nirsevimab is not available as outlined on the palivizumab/Synagis prior authorization (PA) form. 
  • Prior Authorization (PA) forms are available on the PA tab of the MaineCarepdl.org website.
• PA requests for palivizumab for high-risk infants may be submitted beginning November 1, 2024, for dates of administration starting on November 11, 2024. 
  • PA requests will not be approved for any patient who has already received nirsevimab in the same RSV season. 

As detailed in a previous bulletin, OMS academic detailing partner, Maine Independent Clinical Information Service (MICIS), offers one-page non-commercial infographics that share key points for pharmacologic RSV prophylaxis in first, second, and third generations: adults over 60, pregnant people, and infants, respectively. You can request an Academic Detailing session on RSV on the MICIS: Clinical Toolkit.

For questions regarding MaineCare coverage, please contact the Optum Pharmacy Help Desk at 1-888-420-9711. Maine providers can also send inquiries via email.