RSV prophylaxis (palivizumab/Synagis) for high-risk infants and children
Customize your policy alerts
Sign up for Hawaii Department of Human Services Policy FFS 18-05 QI-1813 alerts
Get alerted when Policy FFS 18-05 QI-1813 changes without checking for updates manually.
Monitor payer policy activity
Guideline governing coverage, clinical criteria, dosing schedule, and prior authorization requirements for palivizumab (Synagis) prophylaxis for high-risk infants and children enrolled in Hawaii Medicaid/QUEST Integration for the 2018-2019 RSV season.
No material clinical or coverage changes in this revision.
Coverage Criteria for Palivizumab (Synagis)
Covered Indications
Covered when ANY of the following patient-specific age-and-condition criteria are met at the start of the RSV season
From chunk 3
From chunk 3
Not Covered / Exclusions
Not covered for the following conditions
From chunks 3 and 4
From chunk 4
From chunk 4
From chunk 4
Explicit exclusions to palivizumab (Synagis) prophylaxis are listed to guide appropriate use. Infants and children with hemodynamically insignificant heart disease (examples include secundum atrial septal defect, small ventricular septal defect, mild coarctation, and patent ductus arteriosus) are not covered. Patients with cardiac lesions that have been adequately corrected by surgery are not covered unless they continue to require ongoing medication or supplemental oxygen for heart disease. Children with mild cardiomyopathy that does not require medical therapy are excluded from coverage. These exclusions reflect that palivizumab is intended for prevention in high-risk patients, not for those with minor or corrected cardiac conditions where ongoing medical management is not indicated.
Palivizumab is intended for prevention of respiratory syncytial virus (RSV) and is not medically necessary for patients with an active RSV infection or a documented history of RSV infection during the current RSV season. If a patient is known to have RSV infection, palivizumab should be discontinued because it is not a treatment for active disease.
Coding, Dosing, and Scheduling
| affected codes | The document references prior authorization affected codes but does not list specific CPT/HCPCS/NDC codes. |
Provider Actions and Prior Authorization
PA Required — How to obtain prior authorization
Prior authorization is required for palivizumab. Obtain PA from the member's Medicaid QI health plan (AlohaCare, HMSA, Kaiser Permanente, 'Ohana Health Plan, UnitedHealthcare Community Plan) or Xerox for Koan SHOTT transplant patients. Fax PA requests on the Standardized Prior Authorization Form to 1-888-335-8474. For questions, contact Dr. Curtis Toma, Med-QUEST Division Medical Director, at (808) 692-8106 or ctoma@dhs.hawaii.gov.
- Medicaid QI health plans listed: AlohaCare, HMSA, Kaiser Permanente, 'Ohana Health Plan, UnitedHealthcare Community Plan
- Koan SHOTT transplant program PAs may be obtained from Xerox (pharmacy fiscal agent)
- Fax PA requests on Standardized PA Form to 1-888-335-8474
Denial risk if PA not obtained
Prior authorization is required for palivizumab; failure to obtain prior authorization may result in denial of coverage for Synagis doses.
Administration change — Kapi'olani will provide Synagis administration
Pharmacare will no longer administer Synagis starting with the 2018 season. Kapi'olani Medical Center for Women & Children will offer Synagis administration at its multidisciplinary outpatient clinic and assist with prior authorization and referral arrangements.
- Administration and scheduling available through Kapi'olani Medical Center for Women & Children Neonatology Office
Required referral documentation for Kapi'olani administration
When referring a patient for Synagis administration at Kapi'olani, include the patient's full name, date of birth, date of delivery, gestational age at birth, current diagnosis, and a current progress note; the discharge summary may be used as the referral document.
- Patient name and date of birth
- Date of delivery and gestational age at birth
- Current diagnosis
- Current progress note or discharge summary (may be used as referral document)
Background
Respiratory syncytial virus (RSV) is a leading cause of lower respiratory tract infection in infants and young children, and certain high‑risk groups experience increased morbidity. Palivizumab (Synagis) is a humanized monoclonal antibody approved by the FDA for RSV prophylaxis in high‑risk infants and children and is administered intramuscularly at 15 mg/kg. For the 2018–2019 RSV season in Hawaii, prophylaxis coverage is provided from September 1, 2018 through March 31, 2019, with the first dose on or after September 1, 2018 and subsequent doses given throughout the season for eligible patients who meet the stated age‑and‑condition criteria.
Definitions and Key Terms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.