Palivizumab (Synagis) (CPB 0318, reviewed 2026-08-21)
Summary
Aetna's Clinical Policy Bulletin 0318 covers palivizumab (Synagis) for commercial medical plans and requires precertification from participating providers and members in applicable plan designs. Aetna considers palivizumab medically necessary for up to 5 doses per RSV season to prevent serious lower respiratory tract disease caused by RSV when a member has prematurity, chronic lung disease of prematurity, hemodynamically significant congenital heart disease, a congenital airway abnormality, a neuromuscular condition that compromises handling of respiratory secretions, profound immunocompromise, or cystic fibrosis, and the age, gestational age and clinical criteria for that diagnosis are met. Palivizumab is excluded for members who received nirsevimab-alip (Beyfortus) in the same RSV season. Aetna considers the Synagis season to be November 1 through March 31. For off-season requests, 1 dose per request may be authorized, up to 5 doses per RSV season, if RSV activity for the requested region is at least 3% by real-time PCR within 2 weeks of the intended dose. Aetna considers palivizumab experimental and investigational for asthma, Down syndrome, childhood interstitial lung disease, prevention of health-care associated RSV disease, prophylaxis against RSV in immunocompromised adults, and treatment of RSV.
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