Georgia Medicaid FFS Synagis (palivizumab) prophylaxis — 2015-2016 RSV season
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Defines Georgia Medicaid FFS coverage and prior authorization requirements for palivizumab (Synagis) prophylaxis during the 2015-2016 RSV season for eligible infants and young children, aligned with 2014 AAP/GAAAP guidance.
No material clinical or coverage changes in this revision.
Coverage Criteria for Palivizumab (Synagis)
Covered indications (by risk group)
Covered when ALL of the following are met for each risk group and within season limits:
See dosing table for maximum doses by month of first injection and inpatient first‑dose adjustment
Refer to month‑of‑first‑dose table for exact maximum doses
Second‑year prophylaxis limited to those with medical support in prior 6 months
Decision for cyanotic defects requires pediatric cardiology consultation
See month‑of‑first‑dose table for exact maximum doses and inpatient first‑dose adjustment
Dosing will not be allowed for infants with an active infection or a history of infection during the current season.
Coding and Dose Limits
| ICD-10 | ICD-10 diagnosis codes must be used on the Synagis PA Request Form (specific codes not listed in document). |
Provider Actions, Prior Authorization, and Submission Requirements
Prior authorization required
Palivizumab (Synagis) prophylaxis requires prior authorization. Pharmacy Services prior authorizations must be faxed to OptumRx beginning Sept 21, 2015; Physician Services PAs must be submitted via the Georgia Health Partnership portal as specified.
- OptumRx begins accepting Synagis PA requests on September 21, 2015.
- Pharmacy PAs: fax to OptumRx at 1-888-491-9742.
- Physician Services PAs: submit via Registered User portion of Georgia Health Partnership portal (https://www.mmis.georgia.gov).
Prescriber-only submission and valid signature required
Only prescribers may submit Synagis requests; stamped or copied physician signatures will not be accepted. Providers should ensure the request is completed and signed by the prescribing clinician.
- Requests with stamped or copied physician signatures will not be accepted.
- Only prescribers are allowed to submit requests for Synagis.
PA submission form and routing
Pharmacy Service prior authorization requests must be faxed to OptumRx using the Synagis PA Request Form and must include ICD-10 diagnosis codes; Physician Service prior authorizations must be submitted through the Georgia Health Partnership portal for registered users.
- Use the Synagis PA Request Form available at http://dch.georgia.gov/prior-authorization-process-and-criteria.
- Form must use ICD-10 codes only for Pharmacy Service submissions.
- Fax Pharmacy PAs to OptumRx at 1-888-491-9742; Physician PAs via https://www.mmis.georgia.gov (Registered User portal).
Signature and submitter requirements
Requests submitted with stamped or copied physician signatures will be rejected and only the prescriber may submit Synagis prior authorizations; ensure the prescriber's original signature and submission source are used.
- Do not submit requests with stamped or copied physician signatures.
- Ensure the submitting user is the prescriber (only prescribers may submit).
Definitions and High-Risk Groups
Background and Policy Rationale
The GDCH Synagis policy is based on the 2014 AAP/GAAAP guidance which considered RSV seasonality, palivizumab pharmacokinetics, bronchiolitis hospitalization trends, gestational age and other risk factors, and the limited clinical benefit of prophylaxis. The guidance notes that five monthly doses generally provide more than 6 months of serum concentrations, and the policy uses that evidence to define a seasonal prophylaxis approach and to restrict use to clearly defined high‑risk pediatric populations.
Revision History
Policy effective date establishing Synagis (palivizumab) prophylaxis coverage for Georgia Medicaid FFS for the 2015-2016 RSV season with criteria aligned to 2014 AAP/GAAAP guidance.
OptumRx began accepting Synagis prior authorization requests via Pharmacy Services starting September 21, 2015 using the Synagis PA Request Form with ICD-10 codes.
GDCH allowed RSV prophylaxis with palivizumab to begin October 1, 2015 for the 2015-2016 season with up to five monthly doses and specified eligibility groups.
Standard RSV prophylaxis dosing window ended March 2, 2016 (with specified exceptions allowing dosing through March 31, 2016 for certain high-risk discharges).
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