Independence is announcing the Synagis® (palivizumab)
distribution program for the 2015-2016 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
® (palivizumab) 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® (palivizumab) 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® (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 not considered 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 2015-2016 RSV season, it is mandatory for all participating
providers to obtain Synagis® (palivizumab) through ACRO
Pharmaceutical Services, an independent company.
The following guidelines apply when ordering Synagis®
(palivizumab):
- The RSV Enrollment Form must include sufficient clinical information to
meet our Synagis® (palivizumab) 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 Independence pays ACRO Pharmaceutical Services directly, providers
neither pay for doses ordered through ACRO Pharmaceutical Services nor receive
reimbursement for the actual pharmaceutical.
- Synagis® (palivizumab) 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® (palivizumab) will be
shipped to the provider?s office monthly during RSV season. Shipping for the
2015-2016 RSV season begins on Wednesday, October, 28, 2015, through Thursday,
March 31, 2016. Up to five doses (one dose every 30 days) will be shipped per
member.
To learn more
Review Medical Policy #08.00.22l: Immune Prophylaxis for Respiratory
Syncytial Virus (RSV) to learn more. Visit our Medical Policy Portal,
select Accept and Go to Medical Policy Online, select the
Commercial tab, and then type the policy name or number in the Search
field.
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.