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AmeriHealth 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, AmeriHealth 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. AmeriHealth 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 AmeriHealth 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, call 1-800-275-2583 for
providers in Pennsylvania and Delaware or 1-888-YOUR-AH1 (1-888-968-7241)
for providers in New Jersey.
Note: MedImmune, LLC, the makers of Synagis®
(palivizumab), has a voluntary program called RSV ConnectionTM.
However, AmeriHealth does not participate in this program.
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