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TO: All
Providers
RE: RSV
Prevention Criteria for the 2023–2024 Season
Beyfortus®:
- BeyfortusÒ
(nirsevimab), a long-acting
monoclonal antibody product, was approved by the US Food and Drug
Administration (FDA) on July 17, 2023, for use in newborns and infants to
protect against (medically attended) respiratory syncytial virus (RSV).1
- On August 3,
2023, the Advisory Committee on Immunization Practices (ACIP) of the
Centers for Disease Control and Prevention (CDC) voted unanimously in
favor of recommending use of nirsevimab as indicated in its FDA package
insert.2
- BeyfortusÒ will be administered and dispensed
through the Vaccines for Children Program (VFC)3, administered
through Alabama Department of Public Health. Therefore, BeyfortusÒ will not be eligible for billing through
the Medicaid pharmacy program.
- Procedure codes 90380 and 90381 have
been assigned to BeyfortusÒ. Medicaid VFC providers should refer
to Appendix A, section A.6 of the Provider Billing Manual located at www.medicaid.alabama.gov for
filing claims related to VFC products.
- Based on
guidance from the American Academy of Pediatrics (AAP), if BeyfortusÒ is not available or not feasible to administer,
high risk infants who are recommended to receive SynagisÒ in the first or second year of life
should receive SynagisÒ until BeyfortusÒ becomes available.2
- Per the FDA
label, children who have received BeyfortusÒ should not receive SynagisÒ for the same RSV season.4
Synagis®:
- As a result
of the recommendations for use of BeyfortusÒ, requests for SynagisÒ (palivizumab) will be reviewed on a case-by-case
basis.
- As per normal
criteria, the first dose of SynagisÒ for newborns must be administered
while still inpatient/in the hospital prior to discharge.
- The 2023-2024
season will begin on October 1, 2023. Doses received prior to that date will
not be counted towards the baby’s doses for the 2023-2024 Synagis®
season.
- The approval
time frame for Synagis® for the 2023-2024 RSV season will be
effective October 1, 2023, through March 31, 2024. Up to five doses will
be allowed per baby in this time frame. There are no circumstances that will
result in the approval of a sixth dose*.
- If a dose was
administered in an inpatient setting, the date the dose was administered
must be included on the PA request form. Subsequent doses will be denied
if the baby experiences a breakthrough RSV hospitalization during the RSV
season.
- Prescribers, not the pharmacy, manufacturer or any
other third-party entity are to submit requests for Synagis® on
a specific prior authorization form (Form 351) directly to
Kepro. Completed forms may be accepted beginning September 1, 2023 (for an
October 1 effective date). The fax number for Synagis® requests
is: 1-800-748-0116.
- All
signatures must meet the requirements of Alabama Medicaid Administrative
Code Rule 560-X-1-.18(2)(c). Please note that stamped or copied prescriber
signatures will not be accepted and will be returned to the provider.
- A copy of the
hospital discharge summary from birth or documentation of the first office
visit with pertinent information (gestational age, diagnosis, etc.) is
required on all Synagis® PA requests.
- If approved,
each subsequent monthly dose will require submission of the baby’s current
weight and last injection date. Requests may be faxed to Kepro by the
prescriber or dispensing pharmacy utilizing the original PA approval
letter.
- Prescribers
must prescribe Synagis® through a specialty pharmacy. CPT code
90378 remains discontinued for the 2023-2024 season.
- Medicaid is
the payor of last resort. Claims must be billed to the primary payor if
other third-party coverage exists. Use of NCPDP Other Coverage Codes will
be reviewed, and inappropriately billed claims will be recouped.
*Medicaid will closely monitor
the CDC surveillance information and coordinate with our state pediatric
infectious disease/pulmonary specialist leaders in early 2024 to determine if
changes or an extension of the 2023-2024 season is warranted.
Criteria
Additional questions regarding
Synagis® criteria can be directed to the Agency’s Prior Authorization
contractor, Kepro at 1-800-748-0130.
1https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-prevent-rsv-babies-and-toddlers
2 https://publications.aap.org/redbook/resources/25379
3 Advisory
Committee on Immunization Practices, Vaccines for Children Program (cdc.gov)
4 https://products.sanofi.us/beyfortus/beyfortus.pdf
The Current Procedural Terminology (CPT) and Current Dental Terminology
(CDT) codes descriptors, and other data are copyright © 2023
American Medical Association
and © 2023 American Dental Association (or such other date publication of CPT and
CDT). All rights reserved. Applicable FARS/DFARS apply.