RSV prophylaxis with palivizumab (Synagis) — Hawaii Medicaid QUEST Integration guideline
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Criteria, clinical considerations, and prior authorization requirements for coverage of palivizumab (Synagis) for prophylaxis of respiratory syncytial virus (RSV) in high-risk infants and children for the 2017-2018 RSV season in Hawaii Medicaid QUEST Integration plans.
No material clinical or coverage changes in this revision.
Coverage Criteria for Palivizumab (Synagis)
Covered populations
Covered when ANY one of the following age-based criteria are met at the start of the RSV season:
RSV prophylaxis with palivizumab is not covered for infants and children with hemodynamically insignificant heart disease, including but not limited to secundum atrial septal defect (ASD), small ventricular septal defect (VSD), mild coarctation, and patent ductus arteriosus (PDA). Coverage is also excluded for cardiac lesions that have been adequately corrected by surgery unless the patient continues to require ongoing medication or supplemental oxygen for their heart disease, and for mild cardiomyopathy that does not require medical therapy.
Palivizumab is considered not medically necessary (not covered) for patients who meet any of the explicit exclusion conditions listed above, and it should be discontinued in patients who develop an active RSV infection or have a documented history of RSV infection during the current RSV season.
Provider Actions and Authorization Requirements
Prior authorization required
Prior authorization is required for palivizumab and must be obtained from the member's QUEST Integration (QI) health plan. For patients on the Koan SHOTT transplant program, prior authorizations are obtained from Xerox (MQD pharmacy fiscal agent) with requests faxed as directed.
- Obtain PA from the member's QI health plan (AlohaCare, HMSA, Kaiser Permanente, 'Ohana Health Plan, or UnitedHealthcare Community Plan).
- For Koan SHOTT transplant program patients, submit PA to Xerox (MQD pharmacy fiscal agent) as instructed.
Authorized dosing interval: 28–35 days
Authorizations will cover palivizumab doses administered in intervals of 28–35 days during the declared RSV season.
- Doses covered only when spaced 28–35 days apart during the RSV season (September 1, 2017–March 31, 2018).
Submission method: Standardized PA Form and fax
Submit prior authorization requests using the Standardized Prior Authorization (PA) Form and fax as directed in the policy.
- Fax PA requests for Koan SHOTT transplant program patients on the Standardized PA Form to 1-888-335-8474.
Common exclusion triggers that risk denial
Palivizumab is not covered for infants and children meeting the listed exclusion conditions such as hemodynamically insignificant heart disease and certain corrected cardiac lesions; these are common triggers for denial.
- Hemodynamically insignificant heart disease (e.g., secundum ASD, small VSD, mild coarctation, PDA).
- Cardiac lesions adequately corrected by surgery unless the patient still requires medication or oxygen for heart disease.
- Mild cardiomyopathy not requiring medical therapy.
- Patients with active RSV infection or documented history of RSV infection during the current season (palivizumab should be discontinued if RSV infection occurs).
Definitions and Clinical Terms
Background
Respiratory syncytial virus (RSV) prophylaxis with palivizumab (Synagis) is an FDA‑approved preventive therapy indicated for certain high‑risk infants and young children. This guideline aligns national AAP recommendations with local epidemiology to standardize seasonal use in Hawaii Medicaid QUEST Integration plans and specifies eligibility by age and clinical risk factors at the start of the declared RSV season.
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