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TO:  All Providers

RE:  Synagis^® Criteria for Summer 2021 (as part of the 2020-2021 Season); and the Use of Synagis^® in the 2021–2022 Season

 •    Due to the COVID-19 public health emergency, the Alabama Medicaid Agency (Medicaid) has determined we will review requests for Synagis® on a case-by-case basis for July, August, and/or September 2021 doses. Use of Synagis® in these months is considered part of the 2020-2021 RSV season.

o    Babies that meet criteria and have not yet received their 5 doses for the 2020-2021 season will be considered for July, August, and/or September 2021 doses.
 
o    As per normal criteria, the first dose for newborns must be administered while still inpatient/in the hospital prior to discharge.
 
•    The 2021-2022 season will begin on October 1, 2021. Doses received prior to that date will not be counted towards the baby’s doses for the 2021-2022 Synagis® season.
 
•    The approval time frame for Synagis® for the 2021-2022 RSV season will begin October 1, 2021 and will be effective through March 31, 2022. Up to five doses will be allowed per baby 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 baby experiences a breakthrough RSV hospitalization during the RSV season.  

•    Medicaid updated its prior authorization (PA) criteria for the Synagis®
2021-2022 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

•    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, 2021 (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 that 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 baby’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 2021-2022 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.

*Medicaid will closely monitor the CDC surveillance information and coordinate with our state pediatric infectious disease/pulmonary specialist leaders in early 2022 to determine if changes or an extension of the 2021-2022 season is warranted.

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/Kepro at 1-800-748-0130.