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12 Tips for Getting Synagis Injections Approved

Synagis Vaccine

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Getting Synagis injections approved by insurance companies can be cumbersome, but for me the threat of my babies catching RSV was always worse. So, I stumbled my way through several Synagis approval scenarios. Hopefully, these tips can make your Synagis quest a little easier.

But first, it’s important to understand that there are general guidelines that exist to determine who gets Synagis injections. In the past, babies with a history of prematurity, lung or heart conditions, or extensive hospitalizations who were less than 6 months of age at the beginning of RSV season have been covered. Preemies born at 28 weeks or earlier who were less than one year old often qualified. Preemies or other babies with significant health concerns who were in high-risk situations, such as full-time daycare, exposure to other young children, or being a multiple, sometimes received Synagis injections up to age 2. At the time of this writing, changes to the guidelines are being discussed, so follow up with your pediatrician about whether your child qualifies.

  • Your pediatrician should be supportive of your quest to get Synagis. At a minimum, he or she should be willing to discuss Synagis as an option and why your child may or may not qualify. You are fighting an uphill battle if you have to fight your pediatrician in addition to the insurance company. If your doctor is unfamiliar with Synagis, that person might not be the best fit for a preemie who needs many special considerations in the first years.
  • Your child is likely to be one of a group of children who qualify for Synagis in a pediatrician’s practice. Someone in that practice—usually a nurse—oversees the approval process for your child. Ask who handles Synagis approvals and befriend that person. At our pediatrician’s office, the Synagis nurse and I are now on a first-name basis.
  • Treat the Synagis approval person at your doctor’s office kindly. That person has to deal with all sorts of red tape that would give the most patient person a headache. Feel free to ask plenty of hard questions, but try to end your conversations with how appreciative you are. I really believe there were times we got an injection simply because someone cared about us enough to go the extra mile. Honey catches more flies than vinegar.
  • The dates of RSV season change each year, which impacts the Synagis approval process. In the early fall, the CDC analyzes data to predict the severity of the RSV season and when it will begin by region. Usually, the season occurs during the winter months, somewhere between September and May, but it shifts and changes from region to region and also from one year to the next. My son received injections from October through February, but three years later, my daughter received Synagis from November through April. The approval process is tied to the dates of RSV season. An insurance company will not agree to the injections before RSV season officially begins in a location—or after the season ends. To find out more about your RSV region and regional trends, check out the CDC’s website.
  • Synagis is so expensive that most healthcare providers require pre-approval before they order each monthly injection. When J left the NICU in October, his pediatrician assured us that as a 26-weeker, he was a shoe-in for approval, but as we came within days of his next dose, we still hadn’t received confirmation. I was a basket case because I felt that his health was so fragile. I even offered to pay for Synagis out-of-pocket. Specialized pharmacies usually deliver the injections, Synagis must remain refrigerated, and it must be administered within one or two days of being delivered to a doctor’s office. Pediatricians often don’t want to be responsible for $1000 injections. I discovered that my word meant nothing; if the insurance company didn’t pre-approve Synagis, the specialized pharmacy would not deliver it. Period.
  • You will deal with many different parties when getting approval for Synagis. Your primary insurance company, a secondary insurer if you have one, the specialized pharmacy that supplies the injection, the Synagis person at your doctor’s office, and your doctor. Do not be surprised if one person has no idea what other people have decided. I often had to educate people along the way about why I was calling, what Synagis was, and why it was so important. Sometimes, the person answering the phone had never even heard of Synagis.
  • Don’t rely on anyone else for your child’s approval! Your child’s biggest advocate is you. With my daughter, I heard “no” over and over again, but I would not accept that answer. I called our insurance company. I called the secondary provider. I called our doctor’s office. And if I didn’t like an answer I received, I called more people. I followed up with everyone involved every few days, and I refused to be discouraged. Had I relied on everyone else, I doubt M would have gotten Synagis at all.
  • Don’t take “no” for an answer. You have the right to contest any initial decision, and after you get a second denial, you can usually request a panel at the insurance company to review that decision. Each insurance company has its own process, so call and ask. Then, keep forcing the issue until you get the final denial. With both of my kids, the initial denials were reversed.
  • If you have a secondary provider, don’t forget to use it. If your primary insurer denies Synagis, your secondary provider might cover it. With M, we were caught in a battle of denials between our two providers. Both issued initial denials; the secondary denied because the primary had. When we challenged both decisions, the secondary said the primary insurer had to deny its appeal first. Once that happened, the secondary provider denied M again, saying that it needed written proof from the primary insurer. I demanded the primary send the secondary a denial letter, and then the secondary provider approved M! (See, don’t give up…)
  • Look into a Copay Savings Program. While I didn’t personally need this, our lead blogger, Angie Bickford, did. When insurance just isn’t enough or when you have a big financial hit with beginning of the new year deductibles, these programs can come in handy. Angie was able to get approved for both of her preemies and each of them received the $2,000 financial assistance towards their January – March shots that year.
  • Keep a document listing everyone you contact. I hope your approval process is an easy one, but if you feel like you’re lost in a rabbit hole, having everything documented will make you more organized and focused. Also, you will advocate with more force, because you can say “Becky assured me at noon on Tuesday that the injection would be delivered this Friday by 10 a.m.” All that information allows you to hold people accountable.
  • Ask for help. Talk to other preemie parents. Find out if they have suggestions and if they’re willing to share their experiences. If nothing else, you can share Synagis jokes with them that no one else gets, and laughing through the frustration can save your sanity.

Good luck! If you have additional suggestions, Synagis approval stories, or questions, please feel free to comment. We’ll also be doing a follow-up article once the new guidelines are released, so stay tuned.

Summer Hill-Vinson About Summer Hill-Vinson

Summer (MS) delivered her son 14 weeks early in July 2010 as a result of preterm labor, and he was in the NICU for 3 months. She unexpectedly developed severe preeclampsia with her daughter, almost had her in another state while on vacation, and delivered her 11 weeks premature in January 2013. Both babies weighed 2.5 pounds, and they were in the same NICU for a combined 150 days. Summer, a journalism instructor, is writing a book about her family's NICU years.

Comments

  1. Great article – thanks! I shared this because I know it will help many preemie parents this season. My 23 weeker was approved for 2 seasons of Synagis. He will not get the shot this winter. His lungs have gotten much stronger, but I’m still nervous!

  2. Katherine M says:

    I’m so glad other preemie parents have this article! My daughter was approved for 3 seasons of Synagis, but the last 2 seasons were difficult to get approved. My one additional piece of advice is if you’re seeing a specialist, like a pulmonologist, get them involved as soon as possible. Often their case justification helps push the approval through.

  3. Thanks, Andrea!

  4. Both of my boys were 30 wreckers and were eligible for the Synagis shots based on their age birthweight and season. It was a nightmare to get it approved through the insurance company but I did with both of them. My advice is to be persistent. My doctors office daunt help much. If the insurance company denies you – call someone else. I found out that although it’s a vaccine my insurance considered it an outpatient procedure, which required a different approval. My younger son did develop a slight case of RSV and the doctor said because of the shots his body was able to fight it off. Thanks for the article!

  5. Lindsley Rogers says:

    My son was born in March and was on ECMO for respiratory and cardiac failure…he was on for 10 days, was intubated for 21 and on the vent for over a month. Our initial insurance company approved 5 doses of synagis and then my husbands company switched mid season..we’ve gotten 3 doses and are now being denied…tomorrow I will begin the appeals process and see what other specialists say..but my pediatrician has already done the peer to peer review and they say they are sticking with their decision…anyone have any advice to offer on this?

    • If I were you, I’d go through the entire appeals process, even though they’ve told your pediatrician no. I loved our pediatrician, but I was the one who got our Synagis injections approved after the initial denials. Keep appealing until they tell you that you’ve been given the final answer. I’ve heard that Synagis is even harder to get this year, but don’t let that discourage you. My philosophy was that if my children didn’t get any more Synagis injections, it wouldn’t be because I didn’t do everything I could! Good luck, and I hope you win. And keep up all the good work. Before too long, warmer weather will be here, and RSV season will be in past!

  6. We can afford it out of pocket if we have to…but it would sting…I am appealing tomorrow. So annoyed.

    • Destinee Garrett says:

      My daugther was denied for for her 2nd season of synagis and I am so fuming it not even funny. She was a 27 (ish) weeker and received Synagist the 1st season with no hesitation. Now she is 14 months and has started daycare where every child is SICK and im am a nervous wreck every time I hear her cough or see her runny nose. Now to hear that she is denied for her second season is a HUGH blow. I receive a denial following my pediatricians peer to peer with the insurance company and im a little lost. I suppose i am suppose to be getting something in the mail about the deniels and i will fight these people till the END (mean intense voice). I have been fighting for my daugther since day one and i am not about to let this insurance company get in my way!!!! Its just funny how quicky they give people narcotic pain medications that is harmful for them and approve cosmetic procedures regularly, but for premies to get a medication that they need is like moving heaven and earth. I dont understand it and it blows my mind. I just feel bad because these kids work so hard to be here and keep being here, they go through so many doctors appts, exams, diagnostics, ect. that there shouldnt be another obstical for them to deal with!!
      Well cross your fingers and wish me luck….i wish everyone else luck as well.
      –Many blessings

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