End of the 2022-2023 Seasonal Coverage for Use of Palivizumab Prophylaxis to Prevent Hospitalization from Severe Respiratory Syncytial Virus (RSV) Infection

Mar 09, 2023

The Office of MaineCare Services (OMS), in coordination with their Pharmacy Benefits Manager, Change Healthcare (CHC), reviews data from the Maine Center for Disease Control and Prevention (Maine CDC) to track the epidemic season for respiratory syncytial virus (RSV). The Maine CDC data is used for decision making because it includes a more robust and geographically diverse data set than that provided by the National Respiratory and Enteric Virus Surveillance System (NREVSS).  

As approved by the US Food and Drug Administration, 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. RSV activity typically occurs between November and March, peaking in January or February. OMS and CHC monitor RSV activity in Maine to determine the end of coverage for palivizumab.  

The Maine CDC has reported a steady decline on positive PCR tests with a positivity rate of less than 3% since January 22, 2023. OMS and CHC criteria for acceptance of Prior Authorization (PA) requests for coverage of palivizumab is when the percent positive PCR tests is greater than 3% for two consecutive weeks. Likewise, the criteria utilized to indicate the end of the epidemic season occurs when there are two weeks with less than 3% positivity for PCR testing. Since the Maine specific data provided by Maine CDC indicates that the PCR positivity percent of 3% for more than 3 consecutive weeks, MaineCare will no longer accept PA requests for palivizumab starting on March 17, 2023. Scheduled doses will be covered through March 17, 2023.      

Palivizumab prophylaxis is of unproven value when administered outside of the RSV season as defined by the laboratory monitoring parameters as described above. Therefore, no further shipments will be authorized after March 17, 2023.      

For questions, please contact the Change Healthcare Pharmacy Help Desk at 1-888-420-9711. MaineCare providers can also send email inquiries.      

Thank you for your continued support of MaineCare’s pharmacy benefit program.