August 16, 2022

State of Alabama
Press Release: Medicaid

Synagis® Criteria for Summer 2022 (as part of the 2021-2022 Season); and the Use of Synagis® in the 2022–2023 Season



TO: All Providers

RE: Synagis® Criteria for Summer 2022 (as part of the 2021-2022 Season); and the Use of Synagis® in the 2022–2023 Season
  • Due to the COVID-19 public health emergency, the Alabama Medicaid Agency (Medicaid) has determined that requests for Synagis® will be reviewed on a case-by-case basis for July, August, and/or September 2022 doses. Use of Synagis® in these months is considered part of the 2021-2022 RSV season. 
    • Babies that meet criteria and have not yet received their five doses for the 2021-2022 season will be considered for July, August, and/or September 2022 doses.  
    • As per normal criteria, the first dose for newborns must be administered while still inpatient/in the hospital prior to discharge.  
  • The 2022-2023 season will begin on October 1, 2022. Doses received prior to that date will not be counted towards the baby’s doses for the 2022-2023 Synagis® season.
  • The approval time frame for Synagis® for the 2022-2023 RSV season will be effective October 1, 2022, through March 31, 2023. 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 sixth 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.  
  • 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 Kepro. Completed forms may be accepted beginning September 1, 2022 (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. Requests may be faxed to Kepro 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 2022-2023 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 2023 to determine if changes or an extension of the 2022-2023 season is warranted.

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

The Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes descriptors, and other data are copyright © 2022 American Medical Association and © 2022 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.













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