RSV vax Synagis

Good Grief.... If we have to pay toward the deductible, then we would not be able to afford them at all... wow... maybe the money will be the deciding factor... that sucks.... should be our decision.

 

I didn't realize so many didn't qualify for a 2nd year. I believe we did (but I think only for Mitchell because he had respiratory issues). I guess you have to figure if you don't qualify you probably aren't in the at risk group?
Kyrstyn, I am so surprised your girls didn't qualify since one of your girls had airway issues too?

 

I thought the price was per vial and larger babies need more than one vial?

Also, our hospital marks up the price--so they charge 3 times what they buy it for. That is ridiculous but our insurance covered it last year so it wasn't an issue for us.

 

They are very expensive. I think most of the time insurance covers them for one year. I think there have to be current health issues sometimes to get a second year covered.

Very good point Jen. :good:

I believe that the dosage is done by weight. I can remember as my two got bigger they had to get 2 shots each.
Not sure about the price per vial though.

 

The shots are very expensive and the dosage is determined by weight. Our home health nurse brought a scale with her last year for each visit and my boys had to be weighed each month before she could draw up the medication.

Well, after being told by the nurse at our ped's office that our boys would receive Synagis for a second year, I received a denial letter in the mail today for one of my boys from our insurance company (I'm assuming the other is one its way)!

For anyone who is interested, here are the criteria, outlined in the letter, that they must meet per our insurance company:

Patients must be/have:
- < or = 24 months as of 11/1 with hemodynamically significant heart disease (gives a lengthy definition)
- < or = 24 months as of 11/1 with chronic lung disease (gives a lengthy definition)
- cystic fibrosis diagnosed by positive sweat test or two mutations and who are <13 kg as of 11/1
- a history of prematurity who were <28 weeks gestational age at birth and who are <12 months as of 11/1
- a history of prematurity who were 29-32 weeks gestational age at birth and who are <6 months as of 11/1
- a history of prematurity who were 32-34w6d gestational age at birth and who were born <3 months before the onset of RSV season AND for whom at least one of two risk factors apply: currently attends day care and/or has a sibling <5 years of age

Based on their review, our boys were 26 weekers and are now 13 months old and; therefore, do not qualify. I honestly thought they'd qualify based on the gestational age at which they were born and the fact they did/do have chronic lung disease, but, evidently, not per their definition.

I'm pretty disappointed. I am grateful that my boys did not come home on oxygen and have not required any respiratory support post-NICU, but I was happy that they'd have this extra layer of protection for one more year.

I wonder what made the nurse think we were approved. I'll be appealing this, although I realize guidelines are guidelines .

Oh, and one more thing. Notice above it lists "32 weeks" in two of the criteria. Now if I was a mom of 32 weekers, I'd be arguing to be in the 29-32 week group in order to qualify up to 6 months. They should fix that so there's no overlap.

 

We just got the approval for a second year of synagis....woohoo! Our pediatrician had told us it costs about $1000 per vial per kiddo and that it is based on their weight...so the second year is not often covered as it is really costly! Good luck to all and keep fighting for those babies

 

Mine got it for two years, but our insurance would not cover a home health aide. Mine were born at 31 weeks, 4 lbs each and spent 3 weeks in the NICU. I do remember that the Dr.'s office manager got upset with us because when the boys came home, they had received their first shot at the hospital and were due for their second one with the Dr. For some reason, our insurance was still billing their care through me, since for the first 60 days or so their medical bills went through as if they are my medical issues. (I guess to allow parents some time to get their insurance in order) Anyway, because of that, the Dr. office wasn't getting reimbursed for the cost of the shot. She told me that because of the kind of shot it is and why it is administered, doctors can not charge the insurance company for the time it took to give the shot, they could only bill for the actually cost of the medication and since it is so expensive, she refused to schedule us until our insurance okayed the shots. They can't charge an office visit, which is why so many doctors refuse to do it and pass the job on to health care nurses.

 

And a twin counts as a sibling! I believe this is why we were approved last year.

 

Our daughters qualified last year they were born at 32wks they both recieved them from Nov-March. We did not have to wait after the vaccine. I think the girls felt a little cruddy after the vaccine but no different from any other vaccine they've recieved. I was thankful for them.