Date: September 30, 2022
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 Dosing
_______________________________________________________________________________________________________________________________________________________
This notice serves to inform providers that, due to the increased incidence of Respiratory Syncytial Virus (RSV), providers may submit prior approval requests for Synagis (palivizumab) beginning October 1, 2022.
Due to adverse factors, HFS is changing the start date of Synagis coverage for the 2022-2023 season to October 1, 2022 and plans to end coverage on February 28, 2023. 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 (pdf) 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 (palivizumab) Prior Authorization Criteria (pdf) and Synagis (palivizumab) Rounding Criteria (pdf).
The Department will continue to monitor RSV prevalence and extend coverage of Synagis further into 2023 if medically indicated.
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
