Synagis® Criteria for 2020 – 2021 Season


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To: All Providers 

·            The Alabama Medicaid Agency has updated its prior authorization (PA) criteria for the Synagis® 2020- 2021 season. Complete criteria can be found on the website at the following link:


·            The approval time frame for Synagis® will begin October 1, 2020 and will be effective through March 31, 2021. Up to five doses will be allowed per recipient in this time frame. There are no circumstances that will result in the approval of a 6th dose.


·             If a dose was administered in an inpatient setting, the date the dose was administered must be included on the PA request form. Subsequent doses will be denied if the recipient experiences a breakthrough Respiratory Syncytial Virus (RSV) hospitalization during the RSV season. 


·             Prescribers, not the pharmacy, manufacturer or any other third party entity, are to submit requests for Synagis® on a specific prior authorization form (Form 351) directly to Health Information Designs (HID) and completed forms may be accepted beginning September 1, 2020 (for an October 1 effective date). The fax number for Synagis® requests is: 1-800-748-0116.


·             All signatures must meet the requirements of Alabama Medicaid Administrative Code Rule 560-X-1-.18(2)(c). Please note stamped or copied prescriber 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 prescriber or dispensing pharmacy utilizing the original PA approval letter.


·             Prescribers must prescribe Synagis® through a specialty pharmacy. CPT code 90378 remains discontinued for the 2020-2021 season.


·             Medicaid is the payor of last resort. Claims must be billed to the primary payor if other third-party coverage exists. Use of NCPDP Other Coverage Codes will be reviewed and inappropriately billed claims will be recouped.




Alabama Medicaid follows the 2014 American Academy of Pediatrics (AAP) Redbook guidelines regarding Synagis® utilization. For more details, please review a copy of the guidelines found at

Additional questions regarding Synagis® criteria can be directed to the Agency’s Prior Authorization contractor, Health Information Designs at 1-800-748-0130.