With the 2021-2022 respiratory syncytial virus (RSV) season approaching, Harvard Pilgrim would like to remind providers of our policy regarding Synagis (palivizumab), an injection of antibodies used to protect high-risk infants from severe RSV disease.
Synagis requires prior authorization and should be reserved for infants with a history of pre-term birth and children with chronic lung disease or congenital heart disease. For members who qualify to receive five doses, the first dose is typically administered at the beginning of November and the last dose at the beginning of March to provide protection into April.
As the policy notes, slight variations to the RSV season may be announced by state health departments or the Centers for Disease Control and Prevention, which warned in June of a higher than usual number of off-season RSV cases in certain regions and encouraged broader testing for RSV among patients presenting with acute respiratory illness who test negative for SARS-CoV-2, the virus that causes COVID-19. Further details can be found in this CDC Health Alert.
When determining when to begin approving authorization requests for Synagis, Harvard Pilgrim will take any variations in the RSV season and increases in RSV activity into consideration.
To obtain Synagis for a commercial member, clinicians should contact CVS Health—NovoLogix to request authorization. To view the Synagis criteria and access prior authorization forms, please visit our medical drug prior authorization web page. You may request authorization through CVS Health–NovoLogix via phone (844-387-1435) or fax (844-851-0882).
Providers may still obtain Synagis either through buy and bill or specialty pharmacy (CVS Caremark), and members are responsible for their appropriate cost share. If any of your Harvard Pilgrim patients have questions about their cost share for Synagis, please direct them to the Harvard Pilgrim Member Services phone number on the back of their ID card.
You can find general information about Harvard Pilgrim’s Specialty Pharmacy program here. If you have any further questions, please call the Provider Service Center at 800-708-4414.