Use of Nirsevimab and Palivizumab to Prevent Hospitalizations from Severe Respiratory Syncytial Virus (RSV) in High Risk Infants​

Oct 26, 2023

The Office of MaineCare Services (OMS) is currently accepting Prior Authorization (PA) requests for coverage of palivizumab due to the increasing trend of positive RSV tests. The clinical benefit of palivizumab therapy is best realized by timing the administration to coincide with the peak of RSV activity. OMS and Change Healthcare (CHC) will continue to monitor RSV activity and may end PA approvals when the percent positives on antigen tests is ≤ 10% for 2 weeks or the percent positives on PCR tests is ≤ 3% for 2 consecutive weeks.    

OMS, in coordination with their Pharmacy Benefits Manager, CHC, review data from the National Respiratory and Enteric Virus Surveillance System (NREVSS) and Maine Center for Disease Control and Prevention (ME CDC) to track the epidemic season for RSV. Nirsevimab and palivizumab are indicated for the prevention of serious lower respiratory tract disease caused by RSV in infants. Peak RSV activity typically occurs between November and March.    

On October 23, 2023, United States Centers for Disease Control and Prevention (U.S. CDC) released a health advisory notice to communicate interim recommendations regarding the limited supply of nirsevimab, the new preventive antibody to protect infants against severe RSV. For the 2023-2024 season, U.S. CDC recommends prioritizing available 100mg doses of nirsevimab for infants at the highest risk for severe RSV disease. This includes young infants (age <6 months) and infants with underlying conditions that place them at highest risk for severe RSV disease. Recommendations for using 50mg doses remain unchanged at this time. Avoid using two 50mg doses for infants weighing ≥5 kilograms (≥11 pounds) to preserve supply of 50mg doses for infants weighing <5 kilograms (<11 pounds). U.S. CDC further recommends that providers suspend using nirsevimab in palivizumab-eligible children aged 8–19 months for the 2023–2024 RSV season. The American Academy of Pediatrics (AAP) supports the consideration of palivizumab in patients who would be candidates per current eligibility recommendations outlined in our PA form.     

As detailed in a previous bulletin, OMS academic detailing partner, Maine Independent Clinical Information Service (MICIS), offers one-page non-commercial infographics that share key points for pharmacologic RSV prophylaxis in first, second, and third generations: adults over 60, pregnant people, and infants, respectively. You can request an Academic Detailing session on RSV at: https://micismaine.org/contact/     

For questions about MaineCare’s coverage, please contact the Change Healthcare Pharmacy Help Desk at 1-888-420-9711. Maine providers can also send inquiries via email to PBA_Helpdesk@changehealthcare.com.     

AAP GUIDANCE: Palivizumab Prophylaxis in Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection | Pediatrics | American Academy of Pediatrics (aap.org)    

Prior authorization/order forms should be sent directly to Change Healthcare at 888-879-6938. http://www.mainecarepdl.org/sites/default/files/ghs-files/prior-authorization-forms/2023-10-23/synagis-30120-38.pdf