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AmeriHealth is announcing the Synagis® distribution program
for the 2017-2018 respiratory syncytial virus (RSV) season, which is November
through March in the northeastern United States. RSV is the most common cause
of bronchiolitis and pneumonia among children younger than one year.
During the RSV season, AmeriHealth will approve the monthly administration
of Synagis® for infants and children in accordance with the
current recommendations from the American Academy of Pediatrics (AAP). These
recommendations are subject to change based on updated recommendations as
outlined in the AAP policy statement and Red Book®.
Medical necessity criteria for coverage
Synagis® is a humanized monoclonal antibody that provides
passive immunity against RSV. It is intended to decrease the morbidity and
mortality associated with RSV lower respiratory tract disease in high-risk
infants and children.
Immune prophylaxis using Synagis® is considered medically
necessary and covered for a maximum of five doses during the RSV season for
infants and children who meet medical necessity criteria in the policy and who
have any of the following high-risk conditions (according to the AAP criteria):
- chronic lung disease (CLD) of prematurity;
- history of preterm birth (born before 29 weeks, 0 days) for infants who are
younger than 12 months at the start of the RSV season;
- congenital heart disease;
- severe neuromuscular disease;
- congenital abnormalities of the airway;
- cystic fibrosis with nutritional compromise and/or CLD;
- immunocompromised status (e.g., due to transplantation or chemotherapy).
An additional postoperative dose of Synagis® is considered
medically necessary and covered for infants or children younger than 24 months
who are medically stable, meet any of the AAP criteria for immune prophylaxis,
and have undergone one of the following procedures during RSV season:
- surgical procedures that use cardiopulmonary bypass;
- cardiac transplantation.
If an infant or child receiving monthly prophylaxis with
Synagis® experiences a breakthrough RSV hospitalization, then
continued monthly prophylaxis with Synagis® is not considered
medically necessary due to the low likelihood of a second RSV hospitalization
during the same season.
Note: Synagis® is not effective in the treatment of
RSV disease, and it is not approved for this indication.
How to obtain Synagis® for
office use
Synagis® is covered under the member?s medical benefit. For
the 2017-2018 RSV season, it is mandatory for all participating
providers to obtain Synagis® through ACRO Pharmaceutical
Services.
The following guidelines apply when ordering Synagis®:
- The RSV Enrollment Form must include sufficient clinical information to
meet our Synagis® medical policy criteria, which are based on
current AAP recommendations.
- Providers can go to the ACRO
Pharmaceutical Services website to download the (RSV) Synagis Rx
Form. Providers should fax completed forms to 1-877-381-3806.
- Since AmeriHealth pays ACRO Pharmaceutical Services directly, providers
neither pay for doses ordered through ACRO Pharmaceutical Services nor receive
reimbursement for the actual pharmaceutical.
- Synagis® will generally be approved for office
administration only, unless a patient is receiving home nursing services for a
separate indication.
- Upon approval of the request, Synagis® will be shipped to
the provider?s office monthly during RSV season. Shipping for the 2017-2018 RSV
season begins on Tuesday, October 31, 2017, and continues through Thursday,
March 29, 2018. Up to five doses (one dose every 30 days) will be shipped per
member.
To learn more
Review Medical Policy #08.00.22: Immune Prophylaxis for Respiratory
Syncytial Virus (RSV) to learn more. To view this policy, visit our Medical Policy Portal. Select Accept and Go to Medical
Policy Online and then select the Commercial tab from the top of the
page. Then type the policy name or number in the Search field.
If you have questions about the Synagis® distribution
program, please call Customer Service at 1-888-YOUR-AH1 for AmeriHealth
New Jersey or at 1-800-275-2583 for AmeriHealth Pennsylvania.
This is not a statement of benefits. Benefits may vary
based on state requirements, Benefits Program (HMO, PPO, etc.), and/or employer
groups. Providers should use the NaviNet® web portal to view the
member's applicable benefits information. Members should be instructed to call
the Customer Service telephone number listed on their ID card.
NaviNet is a registered trademark of NaviNet, Inc.
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