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Independence is announcing the Synagis^® (palivizumab) distribution program for the 2014-2015 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 1 year.

During the RSV season, Independence will approve the monthly administration of Synagis^® (palivizumab) for infants and children, in accordance with the 2014-2015 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^® (palivizumab) is a humanized monoclonal antibody that provides passive immunity against RSV. It's intended to decrease the morbidity and mortality associated with RSV lower respiratory tract disease in high-risk infants and children.

Immune prophylaxis using Synagis^® (palivizumab) is considered medically necessary and covered for a maximum of five doses during the RSV season for infants and children 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^® (palivizumab) 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^® (palivizumab) experiences a breakthrough RSV hospitalization, then continued monthly prophylaxis with Synagis^® (palivizumab) is considered not medically necessary due to the low likelihood of a second RSV hospitalization during the same season.

Synagis^® (palivizumab) is not effective in the treatment of RSV disease, and it is not approved for this indication.

How to obtain Synagis^® (palivizumab) for office use

Synagis^® (palivizumab) is covered under the member's medical benefit. For the 2014-2015 RSV season, it is mandatory for all participating providers to obtain Synagis^® (palivizumab) through ACRO Pharmaceutical Services, an independent company. Independence will coordinate with ACRO Pharmaceutical Services to facilitate delivery of Synagis^® (palivizumab) to your office.

The following guidelines apply when ordering Synagis^® (palivizumab):

• Synagis^® (palivizumab) will generally be approved for office administration only, unless a patient is receiving home nursing services for a separate indication.
• The RSV Enrollment Form must include sufficient clinical information to meet our Synagis^® (palivizumab) medical policy criteria, which are based on 2014-2015 AAP recommendations.
• Providers can obtain the RSV Enrollment Form by contacting ACRO Pharmaceutical Services at 1-800-906-7798. Providers should fax completed forms to 1-877-381-3806.
• Since Independence pays ACRO Pharmaceutical Services directly, you neither pay for doses ordered through ACRO Pharmaceutical Services nor receive reimbursement for the actual pharmaceutical.
• Upon approval of your request, Synagis^® (palivizumab) will be shipped to your office monthly during RSV season. Shipping for the 2014-2015 RSV season begins on Wednesday, October 29, 2014, and ends on Tuesday, March 31, 2015. Up to five doses (one dose every 30 days) will be shipped per member.

To learn more

To review Medical Policy #08.00.22l: Immune Prophylaxis for Respiratory Syncytial Virus (RSV), go to our Medical Policy Portal and select Accept and Go to Medical Policy Online. Then type the policy name or number in the Search box.

If you have questions about the Synagis^® (palivizumab) distribution program, please call 1-800-ASK-BLUE.

Note: MedImmune, LLC, the makers of Synagis^® (palivizumab), has a voluntary program called RSV Connection?. However, Independence does not participate in this program.

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