It is mandatory for all participating providers to order Synagis for their patients who are Independence members through our Direct Ship Drug Program. PerformSpecialty®, an independent company, facilitates the delivery of Synagis to these providers.
The 2021-2022 Synagis order forms are available online now. Shipping for the 2021-2022 RSV season begins on Thursday, October 28, 2021, and continues through Thursday, March 31, 2022.
How to order Synagis for office use
1. The Synagis order forms are available now. You can complete the form in two ways.
- Printed form: Office staff print the form and write out the member and provider information.
- Fillable form: Office staff type the member and provider information directly onto the form and then print it.
2. Fax the completed form to 1-855-851-4056. Be sure to include any necessary documentation to support the request. Incomplete forms may result in ordering delays.
3. Upon approval of the request, Synagis will be shipped to the provider's office monthly during the RSV season. Up to five doses (one dose every 30 days) will be shipped per member.
Coverage and reimbursement guidance
Synagis is eligible for coverage under the medical benefit for members who meet our coverage criteria. The order form must include sufficient clinical information about the member to meet the criteria, which are based on current recommendations from the American Academy of Pediatrics (AAP) and are subject to change.
The complete list of coverage criteria for Synagis can be found in the Independence Medical Policy #08.00.22o: Immune Prophylaxis for Respiratory Syncytial Virus (RSV).
Synagis is intended to decrease the morbidity and mortality associated with RSV lower respiratory tract disease in high-risk infants and children. It is not effective in the treatment of RSV disease, and it is not approved for this indication.
Since providers do not pay for doses of Synagis ordered through the Direct Ship Drug Program, they cannot receive reimbursement for the drug. However, providers can be reimbursed for the administration of Synagis.
Synagis is only approved for office administration unless a member is receiving home nursing services for a separate indication.
Some regions of the country may have concerns about interseasonal RSV. Independence will follow guidance from the Centers for Disease Control and Prevention (CDC) and the AAP. We will also monitor local and regional trends, including data from the National Respiratory and Enteric Virus Surveillance System (NREVSS). At this time, use of more than five monthly doses of Synagis is not recommended by the U.S. Food and Drug Administration, CDC, or AAP to address interseasonal RSV.
If you have questions about Synagis, please call Independence Blue Cross Customer Service at 1-800-ASK-BLUE (1-800-275-2583) or Independence Administrators Customer Experience at
To access other drug order forms available through the Direct Ship Drug Program, visit our program webpages: