Medicare AdvantagePrior AuthMedium impact
Synagis® (palivizumab) (Revised)
Humana·FL · Pediatrics, Allergy & Immunology, Infectious Disease·Medicare Advantage
Effective date
Jan 1, 2022
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicare Advantage prior authorization policy for Synagis (palivizumab), effective January 1, 2022, with the most recent revision dated February 25, 2026. The policy establishes strict eligibility criteria for RSV prophylaxis in three pediatric populations: premature infants (≤35 weeks gestation, <6 months old), infants with bronchopulmonary dysplasia (≤24 months old with recent medical treatment), and infants with hemodynamically significant congenital heart disease (≤24 months old). A critical geographic requirement mandates that Florida members receive Synagis only during RSV season periods defined by the state, requiring billing teams to verify RSV season timing before approval and claim submission.
Action Required
By March 31, 2026: Billing and clinical review teams must update prior authorization workflows to incorporate the revised Synagis policy, effective immediately given the recent February 25, 2026 revision date. REQUIREMENTS: (1) For ALL Synagis requests from Florida members, verify current RSV season dates by consulting floridahealth.gov before approving claims—do not process outside designated RSV season periods. (2) Create or update prior authorization templates to require documentation of: gestational age ≤35 weeks AND chronologic age <6 months (prematurity); OR age ≤24 months AND medical treatment for BPD within 6 months; OR age ≤24 months AND diagnosis of hemodynamically significant heart disease (CHD with medication for congestive HF, moderate-to-severe PH, or cyanotic disease). (3) Update billing software to flag Synagis claims originating from Florida for geographic validation. (4) Set approval duration logic to 6-month increments initially and on renewal, subject to clinical review override. (5) Train billing staff and providers that Synagis is for RSV PREVENTION only—not treatment—to prevent inappropriate claims. Failure to apply these geographic and age-based restrictions will result in claim denials for non-compliant submissions. Reference the full policy before processing each request at https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a5460d5.