Palivizumab (Synagis)

Covered: palivizumab is covered only for prevention of RSV in specified pediatric high‑risk groups — FDA‑approved indications (preterm infants born <29w0d and ≤12 months at season start; chronic lung disease born <32w0d with >21% O2 for first 28 days and ≤12 months or ≤24 months with medical therapy in the prior 6 months for a second season; hemodynamically significant CHD ≤12 months meeting listed criteria) and approved compendial off‑label groups (congenital airway abnormality or neuromuscular disorder ≤12 months; immunocompromised and cardiac transplant patients <24 months) — and use outside these listed indications is excluded. Key requirements: dosing 15 mg/kg IM once monthly (maximum 5 doses/season), documentation of diagnosis, gestational age/date of birth, weight, oxygen/medical‑therapy history and local RSV‑season timing, and required specialist prescription/consultation for CHD, transplant, or immunocompromised indications.

"Documentation of diagnosis consistent with an FDA-approved indication or an approved compendial use for Synagis."