By Counterforce Health Team in Synagis (palivizumab) —

How to Get Synagis (Palivizumab) Covered by Humana in New York: Complete PA Guide and Appeals Process

Answer Box: Getting Synagis Covered by Humana in New York

Synagis (palivizumab) requires prior authorization from Humana for high-risk infants meeting AAP criteria. Your child must be ≤35 weeks gestational age, have chronic lung disease requiring therapy, or hemodynamically significant congenital heart disease. Submit the PA request through your pediatrician with complete medical records. If denied, you have 65 days to appeal internally, then can request New York's external review through DFS within 4 months. First step today: Call your pediatrician to confirm your child meets high-risk criteria and request they initiate the prior authorization process.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Understanding Your Costs
  4. Manufacturer Copay Assistance
  5. Common Denial Reasons & How to Fix Them
  6. Appeals Process for New York Residents
  7. When to Request External Review
  8. Scripts for Key Conversations
  9. FAQ: Synagis Coverage with Humana

Coverage Requirements at a Glance

Requirement Details Where to Find It
Prior Authorization Required before first dose Humana PA List
High-Risk Criteria ≤35 weeks GA, chronic lung disease, or significant CHD AAP Guidelines
Maximum Doses 5 doses per RSV season (Nov-Mar) Humana Policy
Specialty Pharmacy Must use Humana-preferred network CVS Specialty: 1-800-552-8159
Appeal Deadline 65 days from denial notice Humana Appeals

Step-by-Step: Fastest Path to Approval

1. Verify Eligibility (Patient/Parent)

  • Who: You and your pediatrician
  • What: Confirm your child meets AAP high-risk criteria
  • Timeline: Before RSV season starts (typically October)

2. Gather Medical Documentation (Clinic)

  • Who: Your pediatrician's office
  • What: Birth records, NICU discharge summaries, cardiology/pulmonology notes
  • Submit: Complete medical history supporting high-risk status

3. Submit Prior Authorization (Clinic)

  • Who: Prescribing physician
  • What: Humana PA Request Form
  • How: Humana Provider Portal or fax
  • Timeline: Allow 30 days for standard review, 72 hours for expedited

4. Coordinate Specialty Pharmacy (Patient/Clinic)

  • Who: You or clinic staff
  • What: Contact CVS Specialty at 1-800-552-8159
  • Timeline: Once PA is approved

5. Schedule Monthly Injections (Patient)

  • Who: You and pediatrician's office
  • What: Monthly appointments during RSV season
  • Timeline: Maximum 5 doses from November through March

Understanding Your Costs

Synagis costs approximately $1,820 per 50mg vial, making the full 5-dose course potentially over $9,000. Your out-of-pocket costs depend on several factors:

Medicare Advantage Plans: Synagis is covered under Medicare Part B as a physician-administered drug. You'll typically pay 20% coinsurance after meeting your deductible.

Commercial Insurance: If you have commercial coverage through Humana, costs vary by plan design. Check your formulary tier and copay structure.

Specialty Pharmacy Benefits: Using Humana's preferred specialty pharmacy network may reduce your costs compared to retail pharmacies.

Manufacturer Copay Assistance

The SYNAGIS Copay Program can significantly reduce your out-of-pocket costs if you have commercial insurance:

Eligibility:

  • US or Puerto Rico residents
  • Commercial insurance (not Medicare, Medicaid, or other government programs)
  • No income requirements

Benefits:

  • Up to $6,000 per calendar year in copay assistance
  • Potential to pay as little as $0 per dose

How to Apply: Call SYNAGIS CONNECT® at 1-833-SYNAGIS (1-833-796-2447), Monday-Friday, 8 AM-8 PM EST. The program provides a copay card that works with your commercial insurance.

Counterforce Health helps families navigate insurance denials for specialty medications like Synagis. Our platform analyzes denial letters and creates targeted appeals with the right medical evidence and payer-specific language to maximize approval chances.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Child doesn't meet AAP criteria Submit birth certificate, NICU records, and specialist notes confirming gestational age ≤35 weeks or qualifying conditions
Already received nirsevimab (Beyfortus) Provide documentation that Beyfortus was unavailable or medically contraindicated for your child
Insufficient medical necessity Request cardiology or pulmonology consultation letter specifically supporting Synagis need
Exceeds 5-dose limit Verify timing and confirm each monthly dose aligns with RSV season guidelines
Missing specialist documentation Obtain current letters from pediatric cardiologist or pulmonologist detailing ongoing risk
From our advocates: We've seen families successfully overturn Synagis denials by providing comprehensive birth records and current specialist evaluations. The key is showing ongoing medical supervision for the underlying high-risk condition, not just historical documentation from birth.

Appeals Process for New York Residents

Internal Appeal with Humana (First Level)

Timeline: 65 days from denial notice Response Time: 7 days for Part D drugs, 30 days for medical coverage How to Submit:

  • Online: Humana member portal
  • Phone: 800-867-6601
  • Mail: Complete redetermination form

Required Documents:

  • Original denial letter
  • Medical records supporting necessity
  • Physician letter explaining why Synagis is appropriate
  • Any additional clinical documentation

Expedited Appeals

Request expedited review if waiting could seriously harm your child's health. Humana must respond within 72 hours for urgent cases.

When to Request External Review

If Humana denies your internal appeal, New York residents have strong additional rights through the Department of Financial Services (DFS).

New York External Appeal Process:

  • Timeline: 4 months after final internal denial
  • Cost: Maximum $25 (waived for financial hardship or Medicaid)
  • Decision Time: Standard appeals decided within reasonable timeframe; urgent appeals within 72 hours (24 hours for urgent drug denials)
  • Binding: DFS decision is final and binding on Humana

How to File: Submit through the DFS Portal or contact Community Health Advocates at 888-614-5400 for free assistance.

When working with insurance denials, Counterforce Health provides specialized support for complex prior authorization appeals, helping families compile the right evidence and documentation to strengthen their case.

Scripts for Key Conversations

Calling Humana Member Services

"Hi, I'm calling about prior authorization for Synagis for my child [name], member ID [number]. Can you tell me the current status of the PA request submitted by Dr. [name] on [date]? If it's been denied, I'd like to understand the specific reason and request an expedited internal appeal."

Requesting Expedited Review

"My child is high-risk for severe RSV and the season is starting. Any delay in getting Synagis could seriously jeopardize their health. I'm requesting an expedited review of this prior authorization based on medical urgency."

Specialty Pharmacy Coordination

"I'm calling to set up Synagis delivery for my child. We have Humana coverage and the prior authorization was approved on [date]. Can you confirm the monthly delivery schedule and coordinate with our pediatrician's office for administration?"

FAQ: Synagis Coverage with Humana

How long does Humana prior authorization take in New York? Standard PA decisions take up to 30 days. Expedited reviews are completed within 72 hours if you can demonstrate medical urgency.

What if Synagis isn't on Humana's formulary? Synagis appears on Humana's 2025 prior authorization list, indicating coverage is available with PA approval. If denied for formulary reasons, request a formulary exception with supporting medical documentation.

Can I appeal if my child received some doses but was denied continuation? Yes. If your child started the series but Humana denied subsequent doses, you can appeal each denial separately. Emphasize the medical necessity of completing the full 5-dose course.

Does step therapy apply if we tried other RSV prevention? Humana may require documentation of why nirsevimab (Beyfortus) isn't appropriate before approving Synagis. Your physician should provide medical justification for choosing Synagis.

What counts as "high-risk" for Synagis coverage? Humana follows AAP guidelines: infants ≤35 weeks gestational age, chronic lung disease requiring medical therapy, or hemodynamically significant congenital heart disease.

Can I use retail pharmacy instead of specialty pharmacy? Synagis typically requires specialty pharmacy dispensing due to storage requirements and high cost. CVS Specialty is confirmed in Humana's network.

What if I move to New York mid-season? Contact Humana to transfer your case and ensure continuity. New York's external appeal rights apply to all residents, regardless of when coverage began.

How do I prove my child meets gestational age requirements? Submit birth certificate, hospital discharge summaries, and NICU records clearly documenting gestational age at birth.

Sources & Further Reading

Disclaimer: This information is educational and not medical advice. Coverage decisions depend on individual circumstances and plan details. Always consult your healthcare provider about your child's specific medical needs and contact Humana directly to verify current policies. For free assistance with New York insurance appeals, contact Community Health Advocates at 888-614-5400.

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