Rx for Synagis? Make Sure Your Premature Baby is Covered

When the doctor in the NICU (Neonatal Intensive Care Unit) recommended that we ask our pediatrician about Synagis to help prevent RSV disease, I never envisioned the health insurance nightmare that would follow. I had seen the commercials promoting Synagis, I had read the pamphlet about RSV. I knew the seriousness of this potentially life-threatening disease for premature babies.

According to the American Association of Pediatrics, RSV disease is

“the most common cause of lower respiratory tract infections in children”

“the leading cause of hospitalization for infants younger than one year”

Annually, “RSV disease results in more than 125,000 hospitalizations, and about 2 percent of these infants die.”

What is Synagis?

If your baby was premature, or has heart or lung problems, your doctor will probably recommend a season of Synagis shots.

Synagis is an antibody developed to combat an infectious disease and is prescribed to premature babies and other at risk pediatric patients to help prevent serious lower respiratory tract disease caused by respiratory syncytial virus (RSV). Synagis a monoclonal antibody, which helps protect the patient for about 30 days. The Synagis shot is administered every 30 days during RSV season, beginning 1 month before the season starts.

According to MedImmune, the makers of Synagis, it is “very important for your baby to get all of his or her monthly shots to optimize the benefit of the therapy.” Each shot helps protect your baby for about 30 days, so a new shot is needed each month during the respiratory syncytial virus (RSV) season. The first shot is generally given 1 month before RSV season starts. RSV epidemic “season” usually runs Fall through Spring in most parts of the country.

Synagis is given by a nurse or a doctor and is typically shot into the thigh muscle. The doctor may advise dosing a bit of Tylenol to ease baby’s discomfort caused by the Synagis shot itself. Typically, you and your baby may need to stay in the doctor’s office for up to half an hour after the Synagis shot is given.

Preventing RSV

According to MedImmune, Respiratory syncytial virus (RSV) affects nearly all babies by the age of 2 and in adults and otherwise healthy children, RSV simply causes mild cold-like symptoms. However, RSV can develop into a serious respiratory illness in premature babies and children with other medical conditions.

RSV may be spread through the air via coughing and sneezing, or from hand to eye, nose or mouth contact with an infected person. RSV can even survive for up to 12 hours on nonporous surfaces – think countertops, stair railings, doorknobs. As with any virus, transmission may be prevented with hand washing and proper cleaning.

Increased Risk

Certain health factors increase the risk of acquiring or having a severe RSV infection. Including:

Prematurity (born more than 4 weeks early)

Chronic lung disease

Congenital heart disease

Low birth weight

Multiple births

Family history of asthma

Environment may also contribute to RSV:

Day care attendance

School-age brothers and sisters at home

Crowded living conditions

Now that you know the risks and potential fatality associated with RSV disease, how could you turn down and RSV shot. Before you say yes to the doctor, be aware of possible problems with paying for Synagis.

A Long, Hard BattleAlex received his first shot of Synagis in September, soon after he came home from the hospital. At that time, the Synagis was covered under my health insurance. Because I chose not to go back to work, we switched Alex to his dad’s insurace, which we later found out, does not cover Synagis. I was concerned because according to MedImmune, if a shot is skipped or postponed, baby could be at higher risk for getting serious RSV disease. However, I could not get a straight answer from any medical professional or from MedImmune about the dangers of starting Synagis and then stopping. Were the risks greater than if baby had never received Synagis at all?

Because there were no answers to this one, the only option was to secure payment and dosages of Synagis no matter how long and hard the fight was. Hours and weeks were spent on the phone with the insurance company, with the doctor’s office and with various state agencies. Luckily Alex was on MassHealth when he was born, so technically MassHealth had to cover any healthcare bills that the regular insurace covered. Fortunately, after many phone calls explaining the situation, MassHealth did cover the rest of Alex’s Synagis shots. Eventually, my preemie did receive all his Synagis shots, not always on time. He did not get RSV and he is off the preemie chart and will not need Synagis again this year. Be Sure About Your Insurance

1. Synagis is not covered by all health insurances – even the expensive ones. If baby was covered under mom’s insurance when born, but will be under dad’s insurance when mom decides to stay home or only work part-time, you must call the new insurance company to check if Synagis is covered. Just because a premature baby needs Synagis, do not assume it will be covered.
2. Don’t assume the person on the phone at the insurance company knows anything about Synagis. In my experience, the insurance company kept referring me to the mail order portion of their service. A couple of people I spoke with had never even heard of Synagis. Remember, you know more about Synagis at this point than they do.

3. The out-of-pocket cost of Synagis is incredibly high and increases with each dosage. Each monthly dosage of Synagis is based on baby’s weight. As baby grows, so does the dosage, and so does the cost. At one point during RSV season for my preemie, the Synagis dose cost $4500.

4. The doctor’s office has to order each dose of Synagis and can only do so after they receive approval from the insurance company. The onus falls upon the parent to call the doctor’s office and be sure the order will be arriving before the next scheduled Synagis shot appointment. Many factors can affect delivery: slow insurance company approvals, mail holidays or doctor’s office closings.

Agencies that Help Defer the Cost

When insurance does not or will not cover the cost of Synagis to prevent RSV disease, there are other options.

1. Check your local state health agency. They may have emergency coverage available, or other health insurance options at little or no cost.

2. Contact Partnership for Prescription Assistance. They can help qualifying patients who lack prescription coverage get the medicines they need through the public or private program that’s right for them.

Synagis can be a potentially life-saving medicine. Discuss further questions or concerns with your health care practitioner.

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