The American Academy of Pediatrics (AAP) recommends the use of palivizumab (Synagis), an
RSV monoclonal antibody vaccine, to prevent serious RSV illness in qualifying high-risk infants.
In July 2009, AAP recommendations changed (Red Book 28 th edition) and are incorporated into the following HPSJ, SJHA and Network Plus Synagis Qualification Criteria:
1. Ex-premature infants 28 weeks and 6 days or less at birth, and chronological age less than 12 months at start of RSV season.
Infants receive no more than five doses during the season.
2. Ex-premature infants 29 weeks 0 days through 31 weeks and 6 days gestation at birth, and chronological age less than 6 months at start of RSV season. Infants receive no more than five doses during the season.
3. Infants 32 weeks,0 days through 34 weeks, 6 days gestation at birth, and less than 3 months chronological age at start of RSV season, with at least one of the following risk factors: a. Infant attends child care defined as a home or child care facility where care is provided for any additional infants or toddlers from another home in the home or child care facility. b. Infant has a sibling (or another child) younger than age 5 living permanently in the household.
Administration of Synagis in this group is not recommended after 3 months of age.
For infants less than 32 weeks estimated gestational age, prophylaxis should continue throughout the season to maximum of 5 doses. Over 32 weeks EGA, administration of Synagis is not recommended after 3 months of age.
Children with any CCS qualifying diagnosis should be referred to CCS for ongoing case management and Synagis authorization should be obtained through CCS. Please refer to CCS
NL: 04-0509 for complete details (available at http://www.dhcs.ca.gov/services/ccs/Documents/ccsnl040509.pdf
).
Palivizumab is a benefit for CCS clients, regardless of the eligible medical condition, who also meet one of the following criteria:
1. Children who meet the above criteria and have a CCS condition.
2. Children 24 months of age or younger at the start of RSV season with Chronic Lung
Disease (CLD) requiring medical treatment (supplemental oxygen, bronchodilator, diuretic, corticosteroid, or other treatment) within six months before the anticipated start of the RSV season. Children who are 24 months of age or younger at the start of RSV
1

season with cyanotic or acyanotic CHD and the request for service is from the CCS approved Cardiac Special Care Center (SCC) or a cardiologist from a CCS approved
Cardiac SCC, or the request is from a CCS approved pediatrician authorized in conjunction with a CCS approved Cardiac SCC or a CCS approved cardiologist from the
Cardiac SCC. Note: The approved cardiologist must be in agreement, if the pediatrician is requesting Palivizumab.
3. Children with severe immunodeficiencies (e.g., severe combined immunodeficiency, acquired immunodeficiency syndrome, transplant recipients, or children who are immunocompromised due to chemotherapy) and the request for service is from a CCS approved Infectious Disease and Immunologic Disorder SCC, Transplant SCC,
Hematology/Oncology SCC, or the request is from a CCS approved pediatrician authorized in conjunction with one of these CCS approved SCCs. Note: The approved
SCC must be in agreement, if the pediatrician is requesting Palivizumab
4. Infants born before 35 weeks of gestation and who are in the first year of life who have either congenital abnormalities of the airway or a neuromuscular condition that compromises handling of respiratory secretions
Please note: Premature infants who are currently only eligible for diagnostic services through the high-risk infant follow-up program are not eligible for authorization of Palivizumab through
CCS and should be authorized through HPSJ
Obtain the Synagis Authorization/Order Form on DRE or the website and submit by fax to
(209) 942-6302. A single authorization is required for the series.
If approved, this authorization will be for a maximum of 5 monthly injections between November
1, 2010 and March 31, 2011* for infants < 32 weeks EGA and until 3 months of age for a maximum of 3 doses for infants > 32 weeks EGA per new AAP recommendations. The approval and order will be faxed by HPSJ to Diplomat Specialty Pharmacy to initiate the procurement process.
* If credible epidemiological evidence indicating new RSV infections extend into April 2011 exists, consideration will be given to add an April dose. Such determination will be made by
March 31, 2011.
Synagis is provided through Diplomat Specialty Pharmacy. Once authorized by HPSJ, Diplomat
Specialty Pharmacy will then contact your office to arrange/coordinate delivery of the approved medications to your office.
When billing for the Synagis injection please bill with the CPT Code 96372 .
2

Diplomat Specialty Pharmacy, the Specialty Pharmacy serving members of Health Plan of San
Joaquin (HPSJ), San Joaquin Health Administrators (SJHA) and Network Plus provides
Synagis.
Diplomat Specialty Pharmacy has many positive features for you and your patients, including:

Delivery of medications directly to your infusion center or office within 24 business hours of approval

Reduced inventory management responsibility for your office

Refills and renewals coordinated by Diplomat Specialty Pharmacy, lessening the burden on your staff

Coordinated monthly scheduling of deliveries

Phone access to pharmacists, nurses, and trained staff to assist HPSJ, SJHA and
Network Plus members

Patient monitoring and education program to improve adherence to prescribed regimens
Any questions regarding scheduling of the patients’ order should be directed to the Diplomat
Specialty Pharmacy Customer service Monday through Friday 8:00 am until 11:00 pm, and
Saturday 8:00 am until 4:00 pm (EST) at 1-877-319-6337.
Synagis is to be given monthly from November through March, the peak RSV months, for a maximum total five doses for infants less than 32 weeks EGA or until 3 months of age for infants
32-35 weeks EGA. RSV is generally seen starting in December in the Western US. A dose given in early March will provide protection into April.
Synagis Clinics:
San Joaquin General Hospital Clinics are no longer offering Synagis injection services
Thank you for caring for young, at risk infants. If you have any questions about the Synagis recommendations, please feel free to call HPSJ Utilization Management Department at
(209) 942-6350.
3