By Counterforce Health Team in Synagis (palivizumab) —

How to Get Synagis (Palivizumab) Covered by Cigna in Pennsylvania: Complete Prior Authorization Guide

Answer Box: Cigna requires prior authorization for Synagis (palivizumab) through Express Scripts/Accredo for high-risk infants meeting AAP criteria. Submit PA using CoverMyMeds or fax (855) 840-1678 with specialist documentation (gestational age, chronic lung disease, congenital heart disease). If denied, use Cigna's internal appeals within 180 days, then Pennsylvania's new Independent External Review within 4 months. First step: Download Cigna's Synagis PA form and gather NICU records today.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing Cigna PA form Cigna Policy
High-Risk Criteria Prematurity ≤35 weeks, chronic lung disease, hemodynamically significant CHD AAP guidelines CDC RSV Guidelines
Seasonal Limits Maximum 5 doses, November-March RSV season timing Cigna PA Form
Specialty Pharmacy Accredo preferred (NCPDP 4436920) Dispensing requirements Cigna Provider Manual
Appeal Deadline 180 days for internal, 4 months for PA external review Pennsylvania regulations PA Insurance Department

Step-by-Step: Fastest Path to Approval

1. Gather Documentation (Patient/Family)

Collect your child's complete medical records including:

  • Birth certificate showing gestational age
  • NICU discharge summary
  • Cardiology or pulmonology consult notes
  • Current weight and age documentation

2. Download and Complete PA Form (Prescriber)

Access Cigna's Synagis prior authorization form and complete all sections, including:

  • Patient demographics and Cigna ID
  • Clinical justification with specific high-risk criteria
  • Dosing schedule (15 mg/kg monthly, up to 5 doses)
  • Preferred dispensing site (Accredo Specialty Pharmacy)

3. Submit via Fastest Channel (Clinic Staff)

Electronic (Preferred): Use CoverMyMeds or EHR integration
Fax: (855) 840-1678 with supporting documentation
Urgent Cases: Call (800) 882-4462 and mark "Urgent" on form

4. Track Response Timeline

  • Standard review: 5 business days
  • Urgent review: 72 hours or sooner
  • Check status via Cigna provider portal or member services

5. If Approved: Coordinate Dispensing

Work with Accredo Specialty Pharmacy (866-759-1557) for delivery and injection scheduling during RSV season.

6. If Denied: Immediate Appeal Steps

Request peer-to-peer review within 7 days and file formal internal appeal within 180 days using denial letter instructions.

7. Pennsylvania External Review (If Needed)

If internal appeals fail, file with Pennsylvania Insurance Department within 4 months of final denial.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Doesn't meet high-risk criteria" Submit specialist letter confirming gestational age ≤35 weeks, chronic lung disease, or hemodynamically significant CHD Birth certificate, NICU records, cardiology/pulmonology notes
"Already received Beyfortus this season" Provide physician statement explaining why Synagis is indicated instead Letter documenting Beyfortus contraindication or supply issue
"Exceeds seasonal dose limits" Demonstrate doses fall within November-March RSV season RSV surveillance data, injection schedule
"Insufficient medical necessity" Include detailed risk assessment and prior respiratory hospitalizations Specialist evaluation, hospitalization records
Clinician Corner: Your medical necessity letter should explicitly state: (1) the child's specific high-risk category per AAP criteria, (2) current clinical status and RSV vulnerability, (3) timing within RSV season, and (4) expected benefit from prophylaxis. Include references to AAP RSV prevention guidelines and document any prior severe respiratory infections.

Appeals Playbook for Pennsylvania

Internal Appeals with Cigna

First Level: Submit within 180 days of denial

  • Use denial letter instructions or member services guidance
  • Include all supporting documentation
  • Request expedited review for urgent cases (72-hour decision)
  • Cigna must respond within 30 days for pre-service appeals

Second Level: If first appeal denied

  • File within specified timeframe in first-level denial letter
  • May include additional clinical evidence
  • Consider peer-to-peer discussion with medical director

Pennsylvania Independent External Review

Pennsylvania launched its own external review program in January 2024, with impressive results: about 50% of appealed denials were overturned in the first year.

Eligibility: Commercial, employer, or Pennie marketplace plans (not Medicare or Medicaid) Timeline: Within 4 months of Final Adverse Benefit Determination Process: File online at PA Insurance Department Decision Time: 45 days standard, 72 hours expedited Cost: Free to consumers

From Our Advocates: We've seen families successfully overturn Synagis denials by submitting comprehensive NICU records alongside current specialist letters that explicitly connect the child's risk factors to published AAP criteria. The key is demonstrating not just eligibility, but urgent medical necessity during RSV season.

When insurers like Cigna face scrutiny over their denial practices, having robust documentation and using Pennsylvania's new external review process can be particularly effective. Counterforce Health helps families and clinicians navigate these complex appeals by identifying the specific denial basis and crafting targeted, evidence-backed rebuttals that align with the plan's own rules.

Costs & Patient Assistance

Estimated Cost: Approximately $1,820 per 50 mg vial (based on Connecticut state pricing) Cigna Coverage: Typically covered as medical benefit through specialty pharmacy Patient Assistance: Synagis offers up to $2,000 copay assistance (patient pays first $30/dose) Application: Contact Synagis CONNECT at 1-833-796-2447

When to Contact Pennsylvania Regulators

Contact the Pennsylvania Insurance Department if:

  • Cigna fails to respond to appeals within required timeframes
  • You need help understanding your external review rights
  • You experience procedural violations during the appeals process

Consumer Services: Available through PA Insurance Department website Pennsylvania Health Law Project: Provides free assistance for complex appeals

FAQ: Synagis Coverage in Pennsylvania

Q: How long does Cigna prior authorization take in Pennsylvania? A: Standard review is 5 business days; urgent cases are decided within 72 hours. Pennsylvania has no state-specific variations to these federal timelines.

Q: What if Synagis is non-formulary on my Cigna plan? A: Request a formulary exception through the standard PA process. Provide clinical justification for why Synagis is medically necessary over formulary alternatives.

Q: Can I request an expedited appeal if my child is high-risk? A: Yes. Mark appeals as "urgent" if standard timing could jeopardize your child's health, especially during active RSV season.

Q: Does step therapy apply if we've tried other treatments outside Pennsylvania? A: Cigna should honor documented treatment failures from any location. Include complete records from previous providers.

Q: What's the success rate for Pennsylvania external reviews? A: In 2024, about 50% of external appeals were decided in favor of patients, resulting in coverage for treatments initially denied.

Q: Can my pediatrician file appeals on my behalf? A: Yes. Physicians can file pre-service appeals for members without requiring an Appointment of Representative form.

The complexity of getting specialty medications like Synagis approved has led many families to seek expert help. Counterforce Health specializes in turning insurance denials into successful appeals by leveraging payer-specific workflows and evidence-backed strategies that meet procedural requirements while tracking crucial deadlines.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions. Insurance coverage varies by plan; verify your specific benefits with Cigna member services. For assistance with Pennsylvania insurance regulations, contact the Pennsylvania Insurance Department's Office of Consumer Services.

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