Synagis® (Palivizumab) – Commercial Medical Benefit Drug Policyopen_in_new

UnitedHealthcare covers Synagis (palivizumab) prophylaxis during the local RSV season only for infants/children meeting specific high-risk indications (e.g., severe prematurity with prolonged oxygen need, chronic lung disease of prematurity, hemodynamically significant CHD, qualifying airway/neuromuscular disorders, severe immunocompromise, and selected cystic fibrosis cases) and excludes use outside the season, therapeutic use for active RSV, continuation after breakthrough RSV hospitalization, routine use for low‑risk conditions (e.g., hemodynamically insignificant CHD, routine Down syndrome or CF), doses >15 mg/kg or >5 monthly doses per season, and patients who received Beyfortus or Enflonsia in the current season. Coverage requires documentation confirming the local RSV season start, patient weight and dose calculations, gestational age and oxygen/medication requirements or pediatric cardiology consultation where applicable, administration records (≤5 doses), and other clinical evidence of the qualifying condition, and the policy notes AAP guidance discontinuing routine palivizumab use as of December 31, 2025.