By Counterforce Health Team in Synagis (palivizumab) —

How to Get Synagis (Palivizumab) Covered by Cigna in Florida: Provider Partnership Guide

Answer Box: Getting Synagis Covered by Cigna in Florida

Synagis (palivizumab) requires prior authorization from Cigna for high-risk infants meeting specific criteria. The fastest path to approval: (1) Confirm your child meets AAP-approved risk factors (premature birth <29 weeks, congenital heart disease, chronic lung disease), (2) Have your pediatric specialist submit Cigna's PA form with detailed medical records to Express Scripts at (855) 840-1678, and (3) If denied, file an internal appeal within 180 days. Start today by gathering your child's medical records and scheduling with a pediatric cardiologist or pulmonologist if needed.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Synagis prescriptions Cigna PA Policy
High-Risk Criteria Premature birth <29 weeks, CHD, chronic lung disease AAP Guidelines
Age Limits Generally <24 months for most conditions Cigna Coverage Policy
Season Limits Maximum 5 doses per RSV season FDA Label
Specialist Required Pediatric cardiology or pulmonology letter Express Scripts PA Requirements
Appeals Deadline 180 days from denial notice Florida Insurance Law

Step 1: Set Your Goal - Understanding What Approval Requires

Getting Synagis covered by Cigna requires proving your child meets strict high-risk criteria and that no alternative treatments are available. Your partnership with your provider is essential - they hold the medical expertise, but you can streamline the process by coming prepared.

Cigna covers Synagis only for infants who meet American Academy of Pediatrics guidelines for high-risk RSV prevention:

  • Premature infants born before 29 weeks gestation
  • Chronic lung disease of prematurity requiring oxygen, diuretics, or steroids in the past 6 months
  • Hemodynamically significant congenital heart disease requiring surgery or heart failure medications
  • Severe immunocompromise or certain other complex medical conditions
Important Note: As of 2025, Synagis is being phased out in favor of newer RSV prevention medications like Beyfortus (nirsevimab). Your doctor must document that these newer options aren't available or appropriate for your child.

Step 2: Prepare for Your Provider Visit

Come to your appointment with a clear timeline and documentation. This preparation helps your doctor write a stronger medical necessity letter and reduces the chance of delays.

Bring This Information:

  • Birth history: Gestational age, birth weight, NICU stay details
  • Current symptoms: Breathing difficulties, feeding problems, growth concerns
  • Treatment timeline: All medications tried, hospitalizations, oxygen use
  • Side effects experienced: From any previous treatments or interventions
  • Functional impact: How RSV risk affects daily life, development, feeding

Questions to Ask Your Provider:

  1. "Does my child meet Cigna's criteria for Synagis coverage?"
  2. "What specific documentation do you need from me?"
  3. "Can you submit the prior authorization today, or what's the timeline?"
  4. "If we're denied, will you be available for a peer-to-peer review call?"

Step 3: Build Your Evidence Kit

Your provider needs comprehensive documentation to support the prior authorization. Gather these materials before your visit:

Medical Records to Collect:

  • Hospital discharge summaries from NICU or cardiac surgery
  • Echocardiogram reports (for heart conditions)
  • Pulmonary function tests or chest X-rays
  • Current medication lists with dosages
  • Growth charts showing failure to thrive (if applicable)

Insurance Documentation:

  • Current Cigna member ID card
  • Summary of benefits (to confirm specialty drug coverage)
  • Any previous denial letters for RSV prevention

Clinical Notes to Request:

  • Recent visit notes mentioning RSV risk
  • Specialist consultations (cardiology, pulmonology)
  • Emergency department visits for respiratory issues
From Our Advocates: "One family we worked with was initially denied because their cardiologist's letter didn't specify that the child's heart defect was 'hemodynamically significant' - the exact language Cigna requires. After adding that specific phrase and attaching the surgical report, the appeal was approved within a week."

Step 4: Work with Your Doctor on the Medical Necessity Letter

The medical necessity letter is your strongest tool for approval. Help your provider include these essential elements:

Required Components:

  1. Clear diagnosis with ICD-10 codes
  2. Specific risk factors that match Cigna's criteria exactly
  3. Prior treatment history and why alternatives aren't suitable
  4. Clinical rationale for Synagis specifically
  5. Risks of delayed treatment for your child's condition

Template Language to Suggest:

"I am requesting prior authorization for Synagis (palivizumab) for [Child's Name], a [gestational age] week former premature infant now [current age] with [specific diagnosis]. This patient meets Cigna's coverage criteria due to [specific risk factor from policy]. The patient has NOT received Beyfortus (nirsevimab) this RSV season and this medication is not available/appropriate because [reason]. Without RSV prophylaxis, this child faces significant risk of hospitalization and respiratory failure."

Supporting Evidence to Include:

  • FDA prescribing information for dosing justification
  • AAP policy statements on RSV prevention
  • Relevant studies from pediatric cardiology or pulmonology literature

Counterforce Health helps families and providers create targeted, evidence-backed appeals that directly address payer criteria like Cigna's specific requirements for Synagis coverage.

Step 5: Support Your Provider During Peer-to-Peer Review

If Cigna requests a peer-to-peer review, your provider will speak directly with a Cigna medical director. You can help by:

Offering Availability Windows: "I know you're busy - would morning or afternoon work better for the peer-to-peer call? I can adjust my schedule to be available if you need any information during the call."

Preparing a Concise Case Summary: Write a one-page summary of your child's key medical facts, previous treatments, and current status. This helps your provider quickly reference important details during the call.

Key Points for Your Provider to Emphasize:

  • Specific high-risk criteria your child meets
  • Why newer RSV prevention options aren't suitable
  • Previous hospitalizations or respiratory complications
  • Current medications and ongoing medical needs

Step 6: Document Everything After Your Visit

Keep detailed records of every interaction with Cigna and your healthcare team:

What to Save:

  • All prior authorization forms and submissions
  • Denial letters with specific reasons cited
  • Provider notes from your patient portal
  • Phone call logs with Cigna customer service
  • Fax confirmations for submitted documents

How to Stay Organized:

  • Create a dedicated folder (physical or digital) for all Synagis-related documents
  • Use your patient portal to message your provider with questions
  • Take photos of insurance cards and important forms as backup

Step 7: Practice Respectful Persistence

Getting specialty drug approvals often requires multiple touchpoints. Here's how to follow up effectively:

Timeline for Updates:

  • Week 1: Confirm prior authorization was submitted
  • Week 2: Check status with Cigna customer service
  • Week 3: If no decision, ask provider to call Cigna directly
  • Beyond 3 weeks: Consider filing a complaint with Florida insurance regulators

How to Escalate Politely: "I understand these reviews take time, but my child's RSV season is approaching. Can you help me understand what's causing the delay and how we can move this forward?"

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Outside labeled high-risk groups" Submit specialist letter confirming specific criteria Cardiology/pulmonology consultation
"Newer alternatives available" Document why Beyfortus isn't suitable/available Provider attestation of unavailability
"Exceeding dose limits" Clarify this is first RSV season or provide weight-based dosing Current weight documentation
"Lack of specialist documentation" Obtain pediatric cardiology or pulmonology letter Specialist consultation within 6 months

Appeals Process for Cigna in Florida

If your initial prior authorization is denied, you have multiple levels of appeal available under Florida law:

Level 1: Internal Appeal

  • Deadline: 180 days from denial notice
  • Timeline: Cigna must respond within 30 days (standard) or 72 hours (urgent)
  • How to file: Cigna Appeals Form
  • Required: Medical records, provider letter, denial notice

Level 2: External Review

  • Deadline: 4 months after final internal denial
  • Process: Independent medical review through Florida Department of Financial Services
  • Cost: Free to consumers
  • Contact: Florida Insurance Consumer Helpline at (877) 693-5236

For Medicare Advantage plans, the process follows federal Medicare timelines with 60-day deadlines at each level.

Frequently Asked Questions

How long does Cigna prior authorization take for Synagis? Standard reviews take up to 5 business days. Urgent requests can be expedited by calling (800) 882-4462.

What if Synagis isn't on Cigna's formulary? You can request a formulary exception with strong medical necessity documentation from your provider.

Can I appeal if my child turns 2 during the RSV season? Coverage typically continues through age 24 months for qualifying conditions, but check your specific plan details.

Does step therapy apply to Synagis? Yes, most plans require trying Beyfortus (nirsevimab) first if available and appropriate for your child's age and risk factors.

What happens if I miss the appeal deadline? You may still file for "good cause" exceptions, but it's much harder to succeed. Act quickly when you receive any denial notice.

How much does Synagis cost without insurance? Approximately $1,820 per 50mg vial as of 2025, with most children requiring 5 monthly doses during RSV season.

When to Escalate Beyond Cigna

If you've exhausted Cigna's internal appeals process, you have additional options in Florida:

Florida Department of Financial Services

  • File insurance complaints online or call (877) 693-5236
  • Request external review for medical necessity denials
  • Free consumer assistance with insurance disputes

Medicare (for Medicare Advantage plans)

  • Contact Medicare directly at 1-800-MEDICARE
  • File complaints about plan administration
  • Request Independent Review Entity (IRE) review

Legal Resources

  • Contact Florida's legal aid organizations for complex cases
  • Consider patient advocacy organizations for rare disease support

The Counterforce Health platform specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed letters that directly address payer-specific requirements like Cigna's Synagis criteria.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for the most current coverage requirements and appeal procedures. Coverage policies and procedures may change without notice.

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