Use of Palivizumab Prophylaxis to Prevent Hospitalization from Severe Respiratory Syncytial Virus (RSV) Infection 

Mar 11, 2022

Effective March 11, 2022, MaineCare will no longer accept Prior Authorization (PA) requests for palivizumab for the treatment of RSV. Scheduled doses will be covered through March 31, 2022. and no further shipments will be authorized after March 31, 2022.  

The Office of MaineCare Services (OMS), in coordination with their Pharmacy Benefits Manager, Change Healthcare (CHC), review data from the National Respiratory and Enteric Virus Surveillance System (NREVSS) to track the epidemic season for RSV.  Palivizumab is indicated for the prevention of serious lower respiratory tract disease caused by RSV in infants who are considered high risk for severe disease. Peak RSV activity typically occurs between November and March, with the most activity in January or February. As mentioned in a previous communication OMS and CHC monitor RSV activity in Maine to determine the end of coverage for palivizumab. NREVSS has reported a steady decline on positive PCR tests with a positivity rate of < 3% since January 22, 2022.  OMS and CHC criteria for acceptance of PA requests for coverage of palivizumab is a percent positive PCR tests of >3% for two consecutive weeks.  With the PCR positivity percent < 3% for five consecutive weeks, MaineCare will no longer accept PA requests for palivizumab. Palivizumab prophylaxis is of unproven value when administered outside of the RSV season as defined by the Centers for Disease and Prevention (CDC) surveillance reports which is why no doses will be covered and no shipments will be authorized after March 31, 2022.    

For questions, please call the Change Healthcare Pharmacy Help Desk at 1-888-420-9711 or email. Thank you for your continued support in administering pharmacy services to MaineCare members. 

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