Applicable to: Mercy Care Complete Care, Mercy Care RBHA, Mercy Care Long Term Care and Mercy Care DD
Respiratory Syncytial Virus (RSV) season typically begins on November 1st of each year and continues through March of the following year.
Synagis (palivizumab) injections to prevent RSV may be provided by any contracted provider for Mercy Care and submitted with CPT Code 90378 - Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each.
Synagis (palivizumab) injections do not require prior authorization.
If you do not wish to buy and bill, Synagis may also be ordered through CVS Specialty Pharmacy and home health nurse visit for injections can be coordinated by CVS Specialty Pharmacy.
The prescription can be sent to CVS Specialty Pharmacy using one of these options:
Phone: 1-800-237-2767
Fax: 1-800-323-2445
E-Prescribe: CVS Specialty
In addition, please click on the following link and be sure to send in the Respiratory Syncytial Virus Enrollment Form along with the prescription for Synagis:
Please be sure to check the box on the form that states Yes, CVS Specialty® to coordinate home health nurse visit for injection.
AAP Summary of Guidance for Palivizumab Prophylaxis:
- In the first year of life, palivizumab prophylaxis is recommended for infants born before 29 weeks, 0 days’ gestation.
- Palivizumab prophylaxis is not recommended for otherwise healthy infants born at or after 29 weeks, 0 days’ gestation.
- In the first year of life, palivizumab prophylaxis is recommended for preterm infants with CLD of prematurity, defined as birth at <32 weeks, 0 days’ gestation and a requirement for >21% oxygen for at least 28 days after birth.
- Clinicians may administer palivizumab prophylaxis in the first year of life to certain infants with hemodynamically significant heart disease.
- Clinicians may administer up to a maximum of 5 monthly doses of palivizumab (15 mg/kg per dose) during the RSV season to infants who qualify for prophylaxis in the first year of life. Qualifying infants born during the RSV season may require fewer doses. For example, infants born in January would receive their last dose in March.
- Palivizumab prophylaxis is not recommended in the second year of life except for children who required at least 28 days of supplemental oxygen after birth and who continue to require medical intervention (supplemental oxygen, chronic corticosteroid, or diuretic therapy).
- Monthly prophylaxis should be discontinued in any child who experiences a breakthrough RSV hospitalization.
- Children with pulmonary abnormality or neuromuscular disease that impairs the ability to clear secretions from the upper airways may be considered for prophylaxis in the first year of life.
- Children younger than 24 months who will be profoundly immunocompromised during the RSV season may be considered for prophylaxis.
- Insufficient data are available to recommend palivizumab prophylaxis for children with cystic fibrosis or Down syndrome.
- The burden of RSV disease and costs associated with transport from remote locations may result in a broader use of palivizumab for RSV prevention in Alaska Native populations and possibly in selected other American Indian populations.
- Palivizumab prophylaxis is not recommended for prevention of health care-associated RSV disease.
As always, don't hesitate to contact your Mercy Care Network Management Representative with any questions or comments. You can find this notice and all other provider notices on our Mercy Care website. We appreciate your participation in our network and your dedication to the health and welfare of our members and your patients.
We appreciate your continued assistance, support, and cooperation! Thanks for all you do!
