Independence is announcing the Synagis? distribution program for
the 2018-2019 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, Independence 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 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, 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 2018-2019 RSV season, it is mandatory for all participating
providers to obtain Synagis? for Independence members through ACRO
Pharmaceutical Services, an independent company.
The following guidelines apply when ordering Synagis?:
- Providers should go to the Independence Direct Ship Drug Program webpage to download the new
RSV Synagis Rx Form.
- The RSV form must include sufficient clinical information to meet our
Synagis? medical policy criteria, which are based on current AAP
recommendations.
- Providers should fax completed forms to
1-877-381-3806.
- Since Independence 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 2018-2019
RSV season begins on Wednesday, October 31, 2018, and continues through
Thursday, March 28, 2019. Up to five doses (one dose every 30 days) will be
shipped per member.
To learn more
Review Medical Policy #08.00.22m: 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, then select
Commercial, and type the policy name or number in the Search field.
If you have questions about the Synagis? distribution program,
please call Customer Service at 1-800-ASK-BLUE.
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., an
independent company.