September 17, 2024

Jefferson Health Plans will start the annual Synagis® Prior Authorization process on October 16, 2024, two weeks before the respiratory syncytial virus (RSV) season begins. Synagis® (palivizumab) is a monoclonal antibody indicated to prevent a severe lower respiratory tract disease caused by RSV in infants and children at high risk. The RSV season begins November 1, 2024, and runs through March 31, 2025.

Jefferson Health Plans is actively monitoring RSV rates in Pennsylvania and any interim guidance published by the American Academy of Pediatrics (AAP). As with previous seasons, if there is an interseasonal change in RSV rates, Jefferson Health Plans will consider the use of Synagis® (palivizumab) in patients who would be candidates per current eligibility requirements before the typical start of the RSV season.  All requests will be reviewed on a case-by-case basis. Please see www.AAP.org for the most recent updates.

SYNAGIS® USAGE

Synagis® reduces RSV hospitalization among high-risk infants and children. In the informed opinion of the American Academy of Pediatrics Committee on Infectious Diseases and the Bronchiolitis Guidelines Committee, as well as others participating in the current statement, Synagis® use should be restricted to appropriate populations, including:

• Infants born before 29 weeks, 0 days gestation and younger than 12 months.
• Infants with congenital heart disease (CHD), chronic lung disease (CLD) or another condition (such as pulmonary abnormality or neuromuscular disease), younger than 12 months and born at 29 weeks, 0 days gestation or later.
• Infants with CLD of prematurity (defined as birth at <32 weeks, 0 days gestation and a requirement for >21% oxygen for at least 28 days after birth) who are younger than 12 months at the start of the RSV season.
• Infants who satisfy the CLD of prematurity definition and continue to require medical support during the 6-month period before the start of the second RSV season and who are between 12 months and 24 months.
• Certain children with hemodynamically significant CHD who are younger than 12 months.
• Children who will be profoundly immunocompromised during the RSV season and are younger than 24 months.

PRIOR AUTHORIZATION PROCESS

If you believe that Synagis® is indicated for your patient, please complete the enclosed Synagis® Prior Authorization Request Form and fax it to 1-866-240-3712 (the form is also available at www.healthpartnersplans.com/providers/prior-authorization). On the request, please identify your preferred network specialty pharmacy that can make arrangements to have the vaccine available for the patient in your office or through a home care provider. A list of network specialty pharmacies can be found at www.hpplans.com/specialtyrx.

Note that coverage for Synagis® is only available when dispensed by a network specialty pharmacy. Please contact our Pharmacy Department at 1-866-841-7659 with any questions you may have.

As always, thank you for being a Jefferson Health Plans provider.