AllMed Webinar Helps Health Plans Determine Medical Necessity for Antiviral Therapy for Influenza

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The Centers for Disease Control and Prevention (CDC) recommends annual vaccination as the best tool for preventing influenza. The CDC also recommends the use of antiviral medications to treat influenza in select patients. During a recent webinar, Dr. Kenneth Hirsch, Associate Medical Director for AllMed, discussed issues related to determining medical necessity for antiviral therapy for influenza.

Flu severity depends on a number of factors, such as what flu viruses are spreading and how much flu vaccine is available. "Timely treatment of influenza," said Dr. Hirsch, "is especially critical for individuals who are at high risk for developing complications, which include pneumonia, bronchitis, and sinus and ear infections." Children under the age of 2 and adults 65 and older are among those at higher risk, as well as patients with certain medical conditions.

According to Dr. Hirsch, antiviral medications are an important adjunct to influenza vaccine in the control of influenza. They can be used either as a treatment for influenza or as chemoprophylaxis to prevent influenza. Since 2006, only the neuraminidase inhibitors oseltamivir and zanamivir have been recommended because of widespread resistance to the adamantanes among influenza A virus strains. Many healthcare plans that include a pharmacy benefit will cover neuraminidase inhibitors for treatment of a diagnosis of influenza, or as a preventive measure as prescribed by a healthcare provider. However, antiviral medications for influenza treatment or chemoprophylaxis are generally not covered for people who are not at higher risk for complications or who do not have severe influenza requiring hospitalization.

While antiviral drugs can help reduce the duration and severity of flu symptoms, the decision to use them must be based on individual evaluations of risk and benefit. It is, therefore, critical for healthcare plans to keep up-to-date on clinical guidelines and new therapies in order to provide the most safe and effective care for patients with influenza.

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