Palivizumab (Synagis)

Palivizumab (Synagis) is covered 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, congenital airway/neuromuscular disorders that impair secretion clearance, profoundly immunocompromised children, and cystic fibrosis with defined severity) with approval limited to up to five monthly doses and adult use not supported. Coverage requires documentation of the FDA‑approved indication or approved compendial use plus specific clinical/age criteria (gestational age and age at RSV season start, oxygen/medical‑support needs or hemodynamic significance or planned transplant for second‑season CHD, immunocompromise status, CF severity or weight‑for‑length <10th percentile, etc.) to justify dosing.

"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)."