CPT Code 96372
The American Academy of Pediatrics (AAP) recommends the use of palivizumab (Synagis), an
RSV monoclonal antibody vaccine, to prevent serious RSV illness in qualifying high-risk infants.
The 2009 AAP recommendations (Red Book 28th edition) are incorporated into the following
HPSJ and SJHA Synagis Qualification Criteria:
Who Qualifies for Synagis Prophylaxis?
Criteria eligible for coverage through HPSJ:
1. Ex-premature infants 28 weeks and 6 days or less at birth, and chronological age less
than 12 months at start of RSV season. Infants receive no more than five doses during
2. Ex-premature infants 29 weeks 0 days through 31 weeks and 6 days gestation at birth,
and chronological age less than 6 months at start of RSV season. Infants receive no
more than five doses during the season.
3. Infants 32 weeks,0 days through 34 weeks, 6 days gestation at birth, and less than 3
months chronological age at start of RSV season, with at least one of the following risk
a. Infant attends child care defined as a home or child care facility where care is
provided for any additional infants or toddlers from another home in the home or
child care facility.
b. Infant has a sibling (or another child) younger than age 5 living permanently in
Administration of Synagis in this group is not recommended after 3 months of age.
For infants less than 32 weeks estimated gestational age, prophylaxis should
continue throughout the season to maximum of 5 doses. Over 32 weeks EGA,
administration of Synagis is not recommended after 3 months of age.
Criteria eligible for coverage through CCS (CCS preauthorization is required).
Children with any CCS qualifying diagnosis should be referred to CCS for ongoing case
management and Synagis authorization should be obtained through CCS. Please refer to CCS
NL: 04-0509 for complete details (available at
Palivizumab is a benefit for CCS clients, regardless of the eligible medical condition, who also
meet one of the following criteria:
1. Children who meet the above criteria and have a CCS condition.
2. Children 24 months of age or younger at the start of RSV season with Chronic Lung
Disease (CLD) requiring medical treatment (supplemental oxygen, bronchodilator,
diuretic, corticosteroid, or other treatment) within six months before the anticipated start
of the RSV season. Children who are 24 months of age or younger at the start of RSV
season with cyanotic or acyanotic CHD and the request for service is from the CCS
approved Cardiac Special Care Center (SCC) or a cardiologist from a CCS approved
Cardiac SCC, or the request is from a CCS approved pediatrician authorized in
conjunction with a CCS approved Cardiac SCC or a CCS approved cardiologist from the
Cardiac SCC. Note: The approved cardiologist must be in agreement, if the pediatrician
is requesting Palivizumab.
3. Children with severe immunodeficiencies (e.g., severe combined immunodeficiency,
acquired immunodeficiency syndrome, transplant recipients, or children who are
immunocompromised due to chemotherapy) and the request for service is from a CCS
approved Infectious Disease and Immunologic Disorder SCC, Transplant SCC,
Hematology/Oncology SCC, or the request is from a CCS approved pediatrician
authorized in conjunction with one of these CCS approved SCCs. Note: The approved
SCC must be in agreement, if the pediatrician is requesting Palivizumab
4. Infants born before 35 weeks of gestation and who are in the first year of life who have
either congenital abnormalities of the airway or a neuromuscular condition that
compromises handling of respiratory secretions
Please note: Premature infants who are currently only eligible for diagnostic services through
the high-risk infant follow-up program are not eligible for authorization of Palivizumab through
CCS and should be authorized through HPSJ
** These criteria apply for SJHA participants. **Authorizations for SJHA
participants will be done through the health plan and should not be referred to
How do I Obtain Authorization and Medication?
Obtain the Synagis Authorization/Order Form on DRE or the website and submit by fax to
(209) 942-6302. A single authorization is required for the series.
If approved, this authorization will be for a maximum of 5 monthly injections between November
1, 2012 and March 31, 2013* for infants < 32 weeks EGA and until 3 months of age for a
maximum of 3 doses for infants > 32 weeks EGA per new AAP recommendations. The
approval and order will be faxed by HPSJ to Diplomat Specialty Pharmacy to initiate the
* If credible epidemiological evidence indicating new RSV infections extend into April 2013
exists, consideration will be given to add an April dose. Such determination will be made by
March 31, 2013.
Synagis is provided through Diplomat Specialty Pharmacy. Once authorized by HPSJ, Diplomat
Specialty Pharmacy will then contact your office to arrange/coordinate delivery of the approved
medications to your office.
When billing for the Synagis injection please bill with the CPT Code 96372.
Diplomat Specialty Pharmacy, the Specialty Pharmacy serving members of Health Plan of San
Joaquin (HPSJ) and San Joaquin Health Administrators (SJHA) provides Synagis.
Diplomat Specialty Pharmacy has many positive features for you and your patients, including:
Delivery of medications directly to your infusion center or office within 24 business hours
Reduced inventory management responsibility for your office
Refills and renewals coordinated by Diplomat Specialty Pharmacy, lessening the burden
on your staff
Coordinated monthly scheduling of deliveries
Phone access to pharmacists, nurses, and trained staff to assist HPSJ and SJHA
Patient monitoring and education program to improve adherence to prescribed regimens
Any questions regarding scheduling of the patients’ order should be directed to the Diplomat
Specialty Pharmacy Customer service Monday through Friday 8:00 am until 11:00 pm, and
Saturday 8:00 am until 4:00 pm (EST) at 1-877-319-6337.
Synagis is to be given monthly from November through March, the peak RSV months, for a
maximum total five doses for infants less than 32 weeks EGA or until 3 months of age for infants
32-35 weeks EGA. RSV is generally seen starting in December in the Western US. A dose
given in early March will provide protection into April.
Since 2010, San Joaquin General Hospital Clinics are no longer offering Synagis injection
Thank you for caring for young, at risk infants. If you have any questions about the Synagis
recommendations, please feel free to call HPSJ Utilization Management Department at