Synagis - BMC HealthNet Plan

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Table 1: Maximum Number of Palivizumab Doses for RSV Prophylaxis of Preterm Infants withoutLung disease, on the Basis of Birth Date, Gestational Age, and Presence of Risk Factors(Shown for Geographic Areas Beginning Prophylaxis on November 1)Maximum No. of Doses for Season Beginning November 129 Weeks, 0 DaysThrough 31 Weeks, 6Days of Gestation and
1. When the above criteria are not met.2. Requests to initiate Synagis ® prophylaxis prior to November 1 st withoutdocumentation confirming an RSV outbreak in a particular geographic region.3. For prophylaxis in patients with cystic fibrosis not meeting any other criteria.Clinical Background Information and References:1. Synagis ® [package insert]. Gaithersburg (MD): MedImmune, LLC; Apr 2013.2. Respiratory Syncytial virus. American Academy of Pediatrics. Red Book: 2012Report of the Committee on Infectious Diseases. Pickering LK, ed. 29th ed. ElkGrove Village, IL: American Academy of Pediatrics; 20123. American Academy of Pediatrics. Modified recommendations for use ofpalivizumab for prevention of respiratory syncytial virus infections. Pediatrics.2009. Dec;124(6): 1964-701.4. Feltes TF; Cabalka AK; Meissner HC; Piazza FM; Carlin DA et al. Palivizumabprophylaxis reduces hospitalization due to respiratory syncytial virus in youngchildren with hemodynamically significant congenital heart disease. J Pediatr2003 Oct; 143(4):532-40.5. Tulloh R; Marsh M; Blackburn M; Casey F; Lenney W et al. Recommendationsfor the use of palivizumab as prophylaxis against respiratory syncytial virus ininfants with congenital cardiac disease. Cardiol Young. 2003 Oct;13(5):420-3.6. Palivizumab is the only RSV immunoprophylactic agent approved for infants withcongenital heart disease. Adapted from: Revised indications for the use ofpalivizumab and respiratory syncytial virus immune globulin intravenous for theprevention of respiratory syncytial virus infections. Pediatrics 2003; 112:1442.7. Drugs at FDA. Available at:http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm. Accessed July26, 2007.Policy History:Effective Date: 09/02/20035/12/2005 – P&T Annual Review1/11/2007 – P&T Annual Review, specific details of the American Academy ofPediatrics RSV Prophylaxis Criteria added.07/10/2008 – P&T Annual Review, no changes requiredThis guideline provides information on BMC HealthNet Plan clinical criteria and claims adjudication processing guidelines. Theuse of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement isbased on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Planpolicies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider.Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the mostrecent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accreditingorganization guidelines and requirements, including NCQA.This document is subject to further revision in response to additional terms and requirements imposed under the Integrated CareProgram, including the ICP contract.BMCHP refers to Boston Medical Center HealthNet Plan in Massachusetts and Well Sense Health Plan in New Hampshire.Boston Medical Center HealthNet Plan and Well Sense Health Plan are trade names used by Boston Medical Center Health Plan,Inc.5 of 7BMC HealthNet Plan – Synagis ®
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