CommercialPrior AuthHigh impact
Palivizumab (Synagis) (CPB 0318, reviewed 2025-11-24)
Aetna·Pediatrics, Infectious Disease, Cardiothoracic Surgery +1 more·Medical Policy
Effective date
Nov 24, 2025
We identified it
Aug 13, 2026
Summary
Aetna has significantly restricted coverage of Palivizumab (Synagis) for commercial plans, now requiring it to be medically necessary only for members with contraindication, intolerance, or ineffective response to the lower-cost alternative Beyfortus. Synagis is now excluded if a member has received Beyfortus in the same RSV season. Prior authorization is required for all Synagis requests, and specific clinical criteria must be met for coverage approval.
Action Required
By December 24, 2025: Billing and clinical teams must implement the following changes: (1) Update billing system to require prior authorization for ALL Synagis (CPT 90378) requests for commercial plans—contact (866) 752-7021 or fax (888) 267-3277 for precertification; (2) Modify encounter forms and templates to document whether patient has previously received Beyfortus in the current RSV season (claims will be denied if Beyfortus was already administered); (3) Ensure providers document one of the seven approved clinical indications (prematurity <29 weeks, CLD, CHD, congenital airway abnormality, neuromuscular condition, immunocompromise, or cystic fibrosis) with specific age/medical criteria met; (4) Train providers that Synagis is limited to 5 doses per RSV season (Nov 1–Mar 31) and off-season requests require CDC NREVSS RSV activity ≥3% in the patient's region; (5) Update claims submission protocols to automatically flag and deny Synagis claims without proof of contraindication/intolerance/ineffective response to Beyfortus. Failure to obtain prior authorization or meet clinical criteria will result in claim denials.