Synagis (palivizumab)

Synagis (palivizumab) is covered only for prevention of serious RSV lower respiratory disease in pediatric patients who meet FDA‑approved or approved compendial indications (prematurity, chronic lung disease, hemodynamically significant CHD, airway abnormalities, neuromuscular disorders, immunocompromise, or cardiac transplant) and is excluded for patients who do not meet the policy’s explicit age, gestational age, oxygen/medical therapy, specialist‑consultation, or transplant/immunocompromise timing criteria. Key requirements include specific gestational‑age and age‑at‑season cutoffs (e.g., <29w0d GA and <12 months for preterm infants; <32w0d GA with >21% O2 for first 28 days for chronic lung disease; CHD <12 months with cardiology/intensivist consult; immunocompromised/transplant <24 months with specialist consult), weight‑based dosing 15 mg/kg IM up to five monthly doses, off‑season dosing only if regional NREVSS activity meets thresholds (≥10% antigen or ≥3% PCR within 2 weeks), and documentation of gestational age, DOB/age, oxygen/medication history, specialist consults, weight, and NREVSS data.