Synagis

Updated qualifications for Synagis in 2010-2011. As you may have already learned RSV is one of the major causes of hospitalization and even death in the premature infant, even after they leave the NICU. However, the insurance companies do not readily cover the only FDA approved medication to help prevent serious RSV- Synagis. Synagis injections are not vaccines, they are a dose of antibodies that last 28=30 days in your child's immune system and help prevent severe RSV disease. They are not guaranteeing your child won't get RSV, but hopefully if they do, the antibodies in their body will help fight it off so the resulting case is not severe. If you have never read about synagis I recommend you go to http://www.synagis.com/how-synagis-works.aspx and talk to your doctor about recommendation for your child. That being said, if you and your doctor decide it's right for your child, that doesn't mean its easy to get! First you need to get an order from your MD, then call your insurance company BEFORE you start them. If you do not talk to your insurance company before and you may be stuck with a hefty bill. The recently updated RSV disease risk assessment states the following:

Children are at high risk for RSV didease:

Children less than or equal to 28 weeks gestation (Born on or after NOV 1, 2009) and are currently less than one year or age at the start of RSV season

29-32 weeks gestation at birth (Born on or after May 1, 2010) and are currently 6 months or younger at he start of RSV season

32-35 weeks gestation at birth (born on or after May 1, 2010) and are less than 6 months of age at the start of RSV season and possess a risk factor *

*Risk factors: school age siblings, day care, less than 12 weeks old at the start of RSV season, exposure to tobacco, less than 2,500 gms at birth, multiple at birth, family hx of asthma, severe neuromuscular disease or congenital abnormalities of the airway

So what if you are over a year at the start of RSV season (this would probably be your second season with a preemie) then you have a different set of risk factors and you need to fight a little harder, insurance companies resist coverage more on the second season for your child

High risk children:

Children with chronic lung disease (BPD eg.) born on or after Nov 1, 2008 and are less than 24 months at the start of RSV season and has had a medical intervention within the last 6 months (oxygen, bronchodialators, diuretic, or corticosteriods)

Children with congenital heart disease born on or after Nov 1, 2008 and are less than 24 months of age at the start of RSV season and have hemodynamically significant CHD.


I hope this information helps. Please use this information when talking with your insurance company about covering synagis for your child. Remember to screen your child early and talk with your insurance company before RSV season is here. My doctor wrote a note to my insurance company about the cost of hospitalization for RSV vs the cost of synagis vaccines and got them to approve coverage for my 24 weeker. Maybe your pediatrician or pulmonogist would be willing to do the same for you. Please update any information or road blocks you guys run into along the way as fall will approach quickly.