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.