CurrentUnitedHealthcarePolicy CSOH2026D0005.C

Synagis® (Palivizumab) (for Ohio Only) – Community Plan Medical Benefit Drug Policy

UnitedHealthcare Community Plan medical benefit drug policy that applies only to Ohio and governs coverage of palivizumab (Synagis) per InterQual criteria, with references to Ohio Administrative Code for medical necessity determinations.

Policy Summary

PayerUnitedHealthcare

PolicySynagis® (Palivizumab) (for Ohio Only) – Community Plan Medical Benefit Drug Policy

Policy CodePolicy CSOH2026D0005.C

Change TypeRoutine reviewno content changes

Effective DateJan 1, 2026

Next Review Date

Key ActionProviders must have requests for Synagis reviewed against the current InterQual Palivizumab criteria and Ohio Administrative Code 5160-1-01 when applicable; coverage is determined by meeting those clinical criteria.

SourceLink

POLICY UPDATE CHANGES

01/01/2026, Summary of Changes = Routine review; no content changes

1Referenced External Criteria (InterQual)

1State Scope (Ohio only)

Coverage Summary

Coverage stance: covered_with_criteria. Scope: UnitedHealthcare Community Plan medical benefit drug policy that applies only to the state of Ohio and governs coverage of palivizumab (Synagis) per the InterQual Specialty Rx Non-Oncology, Palivizumab (Synagis) guideline. Determinations defer to the current release of the InterQual guideline for Palivizumab for indication-specific age, weight, risk factors, dosing, and seasonal administration rules. When conflicts exist between InterQual and federal, state (Ohio Administrative Code (OAC) 5160-1-01), or contractual requirements, the federal/state (OAC) or contractual requirements govern the coverage determination.

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Medical Necessity Coverage Criteria

Coverage is determined using the current release of the InterQual guideline for Palivizumab (Synagis). Synagis is proven and medically necessary for conditions outlined in InterQual when criteria are met.

State Scope: Application limited to members in the state of Ohio; requests evaluated using Ohio Administrative Code 5160-1-01 for services stated as unproven or with coverage/quantity limits.
InterQual Requirement: Member meets clinical criteria specified in the current InterQual guideline: CP: Specialty Rx Non-Oncology, Palivizumab (Synagis).
Refer to InterQual for detailed indication-specific age, weight, risk factors, dosing, and seasonal administration rules.

Prior Authorization & Provider Requirements

Prior Authorization

Prior authorization/evaluation per InterQual and Ohio rules

Providers must have requests for Synagis (palivizumab) reviewed against the current InterQual Palivizumab criteria and, when applicable, Ohio Administrative Code 5160-1-01. Coverage is determined by meeting those clinical criteria.

90378

Documentation Required

Documentation and reference to InterQual and Ohio OAC 5160-1-01

Reference the current InterQual guideline for Palivizumab (Synagis) for indication-specific details including age/weight criteria, dosing, and seasonal administration. Retain documentation that supports medical necessity and comply with Ohio Administrative Code 5160-1-01 for requests involving services stated as unproven or with coverage/quantity limits.

Background & Definitions

This policy applies only to UnitedHealthcare Community Plan members in Ohio. UnitedHealthcare delegates clinical coverage determinations for palivizumab (Synagis) to the externally maintained InterQual Specialty Rx Non-Oncology, Palivizumab (Synagis) guideline. For requests involving services stated as unproven or subject to coverage/quantity limits, evaluations will follow Ohio Administrative Code 5160-1-01. In the event of any conflict, federal, state (OAC), or contractual requirements for benefit plan coverage govern the final determination.