Synagis (palivizumab) benefit transition to Medi-Cal Rx
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Notifies providers that responsibility for Synagis (palivizumab) pharmacy services is transitioning from managed care (Kern Health Systems PBM) to Medi-Cal Rx fee-for-service for dates of service on/after 1/1/2021; it affects providers and beneficiaries who obtain Synagis through Kern Family Health Care.
Pharmacy services for Synagis will transition from the managed care delivery system (Kern Health Systems PBM) to the Medi-Cal Rx fee-for-service system effective January 1, 2021.
Coverage and Transition Criteria
Transition coverage notes
Operational coverage stance during the transition period:
KHS will continue authorization and payment responsibility only through December 2020; post‑transition responsibility moves to DHCS Medi‑Cal Rx.
Billing and Coding Notes
| No codes listed |
Provider Authorization and Operational Actions
Authorization and transition timing
Kern Health Systems will continue to review and authorize medically necessary Synagis (palivizumab) injections beginning in October through December 2020. Claims for Synagis will be paid via the KHS Pharmacy Benefit (PBM) through December 2020; new requests or claims with dates of service after 12/31/2020 will be processed by Medi‑Cal Rx beginning January 1, 2021.
- KHS will review and authorize medically necessary Synagis injections beginning in October through December 2020.
- Claims will be paid via the KHS Pharmacy Benefit (PBM) until December 2020.
- Requests or claims for dates of service after 12/31/2020 will be processed by Medi‑Cal Rx effective 1/1/2021.
Key Definitions
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