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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 palivizumab (Synagis).1 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.1 Despite the importance of UM interventions and the prevalence of PA programs for the use of palivizumab in prophylaxis of respiratory syncytial virus (RSV), to date there have been no peer-reviewed analyses of the clinical, service, or cost outcomes of PA interventions for this high-cost injectable. In this issue of JMCP, Buckley et al. provide the first information in the medical literature regarding the outcomes of a PA intervention to determine coverage for palivizumab. Based on American Academy of Pediatrics (AAP) guidelines, this PA intervention was associated with similar or better clinical outcomes while saving about $2.4 million in palivizumab drug cost over 3 RSV seasons from 2005 through 2008 in a health plan of about 500,000 members.2 Also in this issue of JMCP, Diehl et al. report the results of an exploratory study of the association between compliance with palivizumab and respiratory-related medical utilization in a small sample of children aged 0 to 24 months who met similar AAP-based PA criteria and were immunoprophylaxed during the 2006-2007 RSV season, finding no significant relationships between palivizumab compliance and RSV-related utilization.3

Utilization Management Opportunities for Palivizumab for Prophylaxis of Respiratory Syncytial Virus Complications in Infants