Palivizumab (Synagis®)

Palivizumab (Synagis) is covered only as prophylaxis to prevent serious RSV lower respiratory tract disease in specified pediatric groups (preterm infants, chronic lung disease of prematurity, hemodynamically significant CHD, airway abnormalities, neuromuscular disorders, immunocompromised children, and cardiac transplant patients); other uses are not covered. Coverage requires meeting explicit age/gestational and clinical criteria (e.g., preterm <29w0d and <12 months at RSV season start; chronic lung disease and oxygen/therapy history; CHD/immunocompromise/transplant with relevant specialist prescription/consultation), documentation of eligibility, and is limited to up to five 15 mg/kg IM doses once monthly during the RSV season.

"Approve up to maximum 5 monthly doses (duration limitation)."

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