Utilization management opportunities for palivizumab for prophylaxis of respiratory syncytial virus complications in infants.

摘要

A survey conducted in December 2008 of 69 health plans representing over 83 million commercial, Medicare, and managed Medicaid members found that 81% of the health plans required prior authorization (PA) for coverage of palivi-zumab (Synagis). Palivizumab is commonly covered under the medical benefit (73%) rather than the pharmacy benefit, and is ranked among the therapeutic areas with the highest priority for utilization management (UM). Health plans cite as the primary motivation for targeting palivizumab for UM intervention "to prevent inappropriate use," the same motivation attributed to UM interventions for growth hormones, blood cell stimulants, and omalizumab for asthma.