Policy

Network Health covers Synagis (palivizumab) for Network Health Together^®, Network Health Extend^™, and Network Health Choice members during respiratory syncytial virus (RSV) season, which we define as November 1 – March 31.

Synagis is only available through our specialty pharmacy program as a pharmacy benefit. We will not reimburse for the cost of Synagis as a medical claim when administered in an outpatient setting, since it is a pharmacy benefit. However, we will reimburse for the cost to administer the medication.

Covered conditions 

Network Health will approve Synagis with prior authorization when an infant or child meets all criteria for one of the following conditions:

Chronic lung disease (CLD)

• Member is younger than 24 months old at the start of RSV season, and
• Member has received medical treatments for CLD (bronchodilators, diuretics, or corticosteroids) within the six months prior to RSV season

Congenital abnormalities of the airway or neuromuscular disease

• Member was born at or earlier than 34 weeks, six days gestation, and
• Member is younger than 12 months old at the start of RSV season, and
• Member has compromised handling of respiratory secretions

Congenital heart disease (CHD)

• Member is younger than 24 months old at the start of RSV season, and
• Member has hemodynamically significant acyanotic or cyanotic CHD, and
• Member meets one of the following criteria:
• Member is currently receiving medication to control congestive heart failure, or
• Member has moderate to severe pulmonary hypertension secondary to CHD, or
• Member has cyanotic heart disease

Severe immunodeficiency

• Member is younger than 24 months old at the start of RSV season, and
• Member has severe immunodeficiency, such as severe combined immunodeficiency or severe acquired immunodeficiency syndrome (AIDS)

Prematurity

• Member was born at or earlier than 28 weeks, six days gestation and is younger than 12 months old at the start of RSV season, or
• Member was born between 29 weeks, zero days and 31 weeks, six days gestation and is younger than six months old at the start of RSV season, or
• Member meets all of the following criteria:
• Member was born between 32 weeks, zero days and 34 weeks, six days gestation, and
• Member is younger than three months old at the start of, or was born during, the current RSV season, and
• Member has one of the following risk factors:
• Member attends child care, or
• One or more children younger than five years old live in the same household; multiple births younger than one year old do not qualify as a risk factor  

Quantity limit

Network Health will approve up to five doses of Synagis for use during RSV season if a member meets the criteria described for one of the following conditions:

• CLD
• Congenital abnormalities of the airway or neuromuscular disease
• CHD
• Severe immunodeficiency

Network Health will approve up to the following number of doses for the RSV season for infants who meet the criteria only for the condition of prematurity:

^a Applies to premature infants younger than three months old or those born during the current RSV season with any of the risk factors listed in the covered conditions section, either until the infant reaches three months old or until the end of RSV season, whichever comes first.  
^b Infant may have received Synagis in the previous RSV season if discharged from the hospital during that season. If so, they still qualify for up to five doses in their second RSV season.
^c Network Health will not approve Synagis if the infant is more than six months old at the start of RSV season.
^d Network Health will not approve Synagis if the infant is more than three months old at the start of RSV season.
^e Infant may require fewer doses because of their age at hospital discharge, as the infant will receive one dose every 30 days until they are three months old.     

Guidelines reference

American Academy of Pediatrics (2012). “Respiratory syncytial virus.” RED BOOK Report of the Committee on Infectious Disease, 29^th edition, 609-618.

These guidelines apply to Network Health Together, Network Health Extend, and Network Health Choice plans. Coverage is based on member benefits and eligibility; medical necessity review, where applicable; and the Network Health provider agreement. Adherence to these guidelines by a provider does not guarantee coverage. Network Health reserves the right to amend these guidelines at its discretion. 11162