Palivizumab (Synagis®)

Palivizumab (Synagis) is covered only as prophylaxis (not treatment) to prevent serious RSV lower respiratory tract disease in specified high‑risk pediatric groups (certain preterm infants, chronic lung disease of prematurity, hemodynamically significant CHD, airway/neuromuscular disorders, profoundly immunocompromised children, and cardiac transplant recipients) and is excluded outside these pediatric indications. Approval requires documentation that the patient meets the specific age/gestational‑age and clinical‑severity criteria, specialist prescription/consultation when required, dosing at 15 mg/kg IM once monthly during the RSV season, and a maximum of five monthly doses.

"Prevention of serious lower respiratory tract disease caused by respiratory syncytial virus (RSV) in pediatric patients with a history of premature birth (FDA-approved indication)."

Sign up to see full coverage criteria, indications, and limitations.