CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

RSV immunoprophylaxis (Beyfortus and Synagis)

Policy update describing Neighborhood Health Plan of Rhode Island's preferred RSV prevention approach for the 2023-24 season: Beyfortus (nirsevimab) preferred and state-supplied without prior authorization; Synagis (palivizumab) available only with prior authorization when Beyfortus is unsuitable or if Beyfortus supply is insufficient.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRSV immunoprophylaxis (Beyfortus and Synagis)

Policy CodePolicy N/A

Change TypeRevised preference and authorization guidance

Effective Date2023-24 RSV season (as written)

Next Review DateN/A

Key ActionPrescribers choosing Synagis must obtain prior authorization and provide documentation explaining why Beyfortus is unsuitable and include clinical justification for Synagis use.

SourceLink

POLICY UPDATE CHANGES

Neighborhood now prefers Beyfortus (nirsevimab) over Synagis for RSV prevention and will make Beyfortus available as a state-supplied vaccine without prior authorization.

Beyfortus preferredPreferred RSV prophylaxis

No prior authBeyfortus authorization requirement

Prior auth requiredSynagis authorization requirement

Once every 6 monthsBeyfortus dosing frequency

Six consecutive monthly injectionsSynagis typical dosing course

Coverage Criteria for Beyfortus and Synagis

Beyfortus (nirsevimab) coverage

Covered without prior authorization when provided as the state‑supplied vaccine for eligible populations:

ALL of the following

Intended for all neonates and infants entering their first RSV season
Also intended for children up to 24 months of age who are high risk

Synagis (palivizumab) coverage / prior authorization

Synagis requires prior authorization unless approved because of a Beyfortus shortage. Authorization submissions must include the following:

ALL of the following

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRSV immunoprophylaxis (Beyfortus and Synagis)

Policy CodePolicy N/A

Change TypeRevised preference and authorization guidance

Effective Date2023-24 RSV season (as written)

Next Review DateN/A

Key ActionPrescribers choosing Synagis must obtain prior authorization and provide documentation explaining why Beyfortus is unsuitable and include clinical justification for Synagis use.

SourceLink

On This Page

What Providers Must Do

Prior Authorization

Prior authorization required for Synagis

Prescribers selecting Synagis (palivizumab) must obtain prior authorization before therapy is provided and include documentation explaining why Beyfortus (nirsevimab) is unsuitable and clinical justification for Synagis use.

Documentation Required

Documentation for Synagis PA

The prior authorization submission must include the clinical rationale and specific reasons why Beyfortus cannot be used for the member as part of the authorization request.

Denial Risk

Authorization contingent on Beyfortus availability

Approval of Synagis is contingent on meeting prior authorization criteria; Neighborhood may grant authorization for Synagis if Beyfortus supply is insufficient (Synagis may be approved during Beyfortus shortages).

Clinical and Administrative Background

Neighborhood Health Plan of Rhode Island now prefers Beyfortus (nirsevimab) for prevention of respiratory syncytial virus (RSV) during the 2023-24 season. Beyfortus is given once every six months and is intended for neonates and infants entering their first RSV season and for children up to 24 months of age who are high risk. When provided as the state-supplied vaccine, Beyfortus does not require prior authorization.

If a prescriber chooses Synagis (palivizumab) instead, note that Synagis requires six consecutive monthly injections and will require prior authorization. The authorization request must include documentation explaining why Beyfortus is unsuitable for the member and provide the clinical rationale justifying Synagis use. Neighborhood will monitor Beyfortus supply; if Beyfortus is in shortage, Synagis may be approved for members who meet prior authorization criteria.

OpenPayer

RSV immunoprophylaxis (Beyfortus and Synagis)

Coverage Criteria for Beyfortus and Synagis

What Providers Must Do

Codes and Billing

Clinical and Administrative Background

Key Definitions

Policy Changes