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Synagis® Criteria for 2012 – 2013 Season

August 29, 2012

TO:  All Providers

·         The Alabama Medicaid Agency has updated its prior authorization criteria for the Synagis®  2012-2013 season.  Below are some highlights for the season.  Complete criteria can be found on the website at the following link: 




·         The approval time frame for Synagis® will begin October 1, 2012 and will be effective through March 31, 2013.


·         Up to five doses will be allowed per recipient in this timeframe. Some recipients may only receive up to a max of 3 doses, depending on the gestational and chronological age.


·         There are no circumstances that will result in approval of a sixth dose.


·         If a dose was administered in an inpatient setting, the date the dose was administered must be included on the request form.


·         For approval of requests, the recipient must meet gestational and chronological age requirements. In order to meet chronological age requirements, the recipient must not exceed the specified age at the start of the RSV season.


·         Prescribers, not the pharmacy, manufacturer or any other third party entity, are to submit requests for Synagis® on a separate prior authorization form (Form 351) directly to Health Information Designs and completed forms may be accepted beginning September 1, 2012 (for an October 1 effective date).


·         Stamped or copied physician signatures will not be accepted and will be returned to the provider.


·         A copy of the hospital discharge summary from birth or documentation of the first office visit with pertinent information (gestational age, diagnosis, etc.) is required on all Synagis® PA requests.


·         If approved, each subsequent monthly dose will require submission of the recipient’s current weight and last injection date and may be faxed to HID by the prescribing physician or dispensing pharmacy utilizing the original PA approval letter.


·         Letters will be faxed to both the prescriber and the dispensing pharmacy notating approval or denial.



Alabama Medicaid follows the 2012 American Academy of Pediatrics (AAP) Redbook guidelines regarding Synagis® utilization. Additional questions regarding Synagis® criteria can be directed to the Agency’s Prior Authorization contractor, Health Information Designs at 1-800-748-0130.