Palivizumab (Synagis)

Aetna covers up to five monthly 15 mg/kg doses of palivizumab per RSV season (Nov 1–Mar 31) only for infants meeting specified criteria: prematurity <29w0d and <12 months at season start; CLD of prematurity (GA <32w0d, >21% O2 for first 28 days and either <12 months at first season or <24 months with ongoing medical support in prior 6 months); hemodynamically significant CHD (<12 months, or 12–24 months if undergoing cardiac transplant during the season); or congenital airway abnormality that impairs secretion clearance and <12 months. All other indications (e.g., asthma, Down syndrome, chILD, immunocompromised adults, treatment) are considered investigational, dosing <15 mg/kg or less frequently than monthly is not supported, and coverage is denied if Beyfortus (nirsevimab) was given in the same RSV season.

"Prevention of serious lower respiratory tract disease caused by RSV for up to 5 doses per RSV season when associated criteria are met for any of the following diagnoses/conditions:"