Synagis?

andthatmakes4 · January 2014

DS is 4.5 actual/2.5 adjusted and has had 3 of the Synagis injections. He hasn't received his December shot and between the dr and insurance everyone is pointing fingers at the other person. The latest reason that he isn't getting any more is because he doesn't qualify since he's 3 months old and no longer meets the risk factors. Since we initially qualified for it, we were able to secure at home childcare for him and my daughter which I know is a risk factor but they wouldn't have known about that. I thought if he qualified for Synagis then he would get the injections for the whole season. Anyone else have this random 3 month rule?

ac1259 · January 2014

I just heard what my insurance would cover and they said 2 additional injections. DD had 1 at the hospital and she'll get 2 more but that only puts her covered through 3 months old. But the only risk factor she had was being a late term preemie with a sibling under 5 so that might be why? I'm not sure I fully understand either!

KTZ17 · January 2014

What was his gestational age at birth? I don't understand why he would only qualify for part of RSV season. Edited for typo

flerlgirl · January 2014

KTZ17 said:

What was his gestational age at birth? I don't understand why he would only qualify for part of RSV season. Edited for typo

This. We get all five (the whole season) based solely on his gestational age.

andthatmakes4 · January 2014

He was 32 wks 5 days. That is his only risk factor now that all of the other kids were pulled from day care which sounds like what ac1259 wrote. I have BCBS and maybe this is just their policy. But if I could possibly fight them on it to get him more, I want to.

flerlgirl · January 2014

@usm123, did your son qualify again because of his BPD? My son has that as well and was also a 26 weeker (saaaaamesiiiiiieeeeeeees) with all the fun risk factors. I'm wondering if I should speak to his pulmonologist about doing the RSV shots again.

spin25 · January 2014

My insurance would only authorize 3 shots at a time. We will have to request an additional authorization for the fourth shot they are supposed to receive. It's not that it was denied; they just ok three as a general rule. My LO's were born at 30w4d, if that matters.

PurpleIris30 · January 2014

One of my twins was approved for 3 doses and one for 5 doses. Obviously the same gestational age - born at 32 weeks. One spent 7 more days in the nicu and needed oxygen for a little longer. I have no solutions for you, as this is something I need to get straightened out too. It's perplexing to me that they wouldn't both be covered for the whole season if they qualify.

LaciJaxx · January 2014

Our LO was born at 31w0d and we qualified for 5 shots. That was our only risk factor but our nurse asked me three times if he'd be in public, so I answered that yes we would be taking him to church and she shook her head. I would try to fight it if I were you. It's worth it. Good luck!!!!!

LaciJaxx · January 2014

Also, I believe our pedi told us the standard cutoff GA was 34 weeks, so that shouldn't affect you.

SarahA918 · January 2014

I was told that my son would get them the rest of this season and the rsv season next year. Seems crazy not to qualify midway through the season.

DrRx · January 2014

They base this on the latest AAP guidelines for Synagis prophylaxis.

"Infants born from 32 weeks' 0 days' through 34 weeks' 6 days' gestation who qualify for prophylaxis under the new recommendations should receive prophylaxis only until they reach 90 days of age or a maximum of 3 doses (whichever comes first). This is a change from the previous recommendation for 5 months of prophylaxis."

That was a copy and paste from the site. Here is the link to the article in the Journal of American Association of Pediatrics. Most insurance companies will base their coverage criteria based on this.

https://pediatrics.aappublications.org/content/124/6/1694.full.html

LaciJaxx · January 2014

Thanks for posting that article. Very informative!

This pretty well sums it up, but I suggest reading the whole article.

https://pediatrics.aappublications.org/content/124/6/1694/T3.expansion.html

andthatmakes4 · January 2014

Thank you for all of the responses and the AAP link. We are on lockdown and wash down from when we do go out so hopefully this will be enough to keep him safe from RSV.

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