AmeriHealth 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, AmeriHealth 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 AmeriHealth members through ACRO Pharmaceutical Services.

The following guidelines apply when ordering Synagis^?:

• Providers should go to the Direct Ship Drug Program webpage for AmeriHealth New Jersey or AmeriHealth Pennsylvania 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 AmeriHealth 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 Policies, 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 1-888-YOUR-AH1 for AmeriHealth New Jersey or at 1-800-275-2583 for AmeriHealth Pennsylvania.

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.

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