CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Rsv Prevention Update

Guidance for the 2023-24 RSV season specifying preferred use of Beyfortus (nirsevimab) for neonates/infants and certain high-risk children up to 24 months; operational notes on prior authorization and vaccine supply for Beyfortus and Synagis.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRsv Prevention Update

Policy CodePolicy N/A

Change TypeAdded recommendation

Effective Date

Next Review Date

Key ActionWhen requesting authorization for Synagis, document why Beyfortus is unsuitable for the member and include clinical information that justifies the need for Synagis.

SourceLink

POLICY UPDATE CHANGES

Recommendation to administer Beyfortus (nirsevimab) before using Synagis for the 2023-24 RSV season.

2023-24RSV season applicable

onceBeyfortus dosing frequency

sixSynagis dosing frequency

Summary of material changes

Neighborhood Health Plan of Rhode Island now recommends Beyfortus (nirsevimab) as the preferred RSV prophylaxis for the 2023-24 season: it is intended for neonates and infants entering their first RSV season and for certain high-risk children up to 24 months. Beyfortus will be state-supplied and will not require prior authorization.

The alternative product, Synagis (palivizumab), remains available but requires prior authorization. Authorization for Synagis must document why Beyfortus is unsuitable for the member and include clinical justification for Synagis use. See the changes_list for granular change entries.

Scope and key stats

RSV season applicable2023-24

Beyfortus dosing frequencyonce every six months

Synagis typical dosing frequencysix monthly injections

ScopeGuidance for the 2023-24 RSV season specifying preferred use of Beyfortus (nirsevimab) for neonates/infants and certain high-risk children up to 24 months; operational notes on prior authorization and vaccine supply for Beyfortus and Synagis.

Preferred product and authorization requirements

Preferred Product and Authorization Requirements

Policy guidance for product selection and authorization:

ALL of the following

Beyfortus (nirsevimab) is recommended before use of Synagis for the 2023-24 RSV season.
Beyfortus is intended for all neonates and infants entering their first RSV season.
Beyfortus is intended for children up to 24 months who are high risk.
Authorization rules
- Beyfortus will not require prior authorization and will be available as a state-supplied vaccine.
- Synagis (palivizumab) requires prior authorization for prescribers wishing to obtain it.
Authorization for Synagis must document why Beyfortus isn't suitable for the member and include clinical justification for Synagis use.

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What providers must do

Prior Authorization

Prior authorization required for Synagis

Synagis requires prior authorization; Beyfortus does not require prior authorization.

Beyfortus will be state-supplied.

Documentation Required

Document rationale to obtain Synagis

When requesting authorization for Synagis, document why Beyfortus is unsuitable for the member and include clinical information that justifies the need for Synagis.

Billing Rule

Beyfortus availability as state-supplied vaccine

Beyfortus will be available as a state-supplied vaccine and will not require prior authorization.

Operational note: Synagis will require prior authorization while Beyfortus is state-supplied and does not require prior authorization.

Key terms

Beyfortus: Nirsevimab; an immunization given once every six months intended for neonates and infants entering their first RSV season and for certain high-risk children through 24 months.

Synagis: Palivizumab; an RSV prophylactic that typically requires six monthly injections and now requires prior authorization with documentation explaining why Beyfortus is not suitable.

Policy updates

2023-24Policy changeLatest

Recommendation to administer Beyfortus (nirsevimab) before using Synagis for the 2023-24 RSV season; Beyfortus is intended for neonates/infants entering their first RSV season and high-risk children up to 24 months, will be state-supplied and will not require prior authorization. Synagis (palivizumab) remains available but requires prior authorization with documentation of why Beyfortus is unsuitable and clinical justification for Synagis use.