· 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: http://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME/4.3.10_Synagis.aspx
· 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.
Criteria
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 http://pediatrics.aappublications.org/content/early/2014/07/23/peds.2014-1665.
Additional questions regarding Synagis® criteria can
be directed to the Agency’s Prior Authorization contractor, Health Information
Designs at 1-800-748-0130.