Date: August 5, 2021
To: Enrolled Physicians; Advanced Practice Nurses: Physician Assistants; Local Health Departments; Hospitals; Federally Qualified Health Centers; Rural Health Clinics; Encounter Rate Clinics; and Pharmacies
Re: Prior Approval Requests for Synagis
This notice serves to inform providers that, due to the increased prevalence of Respiratory Syncytial Virus (RSV), providers may submit prior approval requests for Synagis (palivizumab) effective immediately. This applies to customers covered under Medicaid fee-for-service or a managed care plan. Providers should contact the appropriate managed care plan for approval guidance.
For fee-for-service customers, providers must complete the Drug Authorization Request Form for Synagis and fax it to the Pharmacy Unit at 217-524-7264. Approval for the early dosing will be provided for those customers who meet the Department's Synagis Prior Approval Criteria.
For both fee-for-service and managed care customers, the approval period for the dose will be effective through August 31st.
This is a temporary deviation from the usual Synagis guidelines and the Department will continue to monitor RSV prevalence and respond accordingly.
Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565, or to the appropriate managed care plan.
Kelly Cunningham, Administrator
Division of Medical Programs