NYRx, the Medicaid Pharmacy Program

Prior Authorization Call Line: 1-877-309-9493
Prior Authorization Fax Line: 1-800-268-2990

Prior Authorization for Synagis® has been implemented to ensure that Synagis® is utilized within the respiratory syncytial virus (RSV) season and in a medically appropriate manner. Criteria is aligned with the most recent American Academy of Pediatrics (AAP) Guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for RSV infection. The prescriber or an authorized agent can initiate the PA process for Synagis®. An authorized agent is an employee of the prescribing practitioner and has access to the patient's medical records (i.e. nurse, medical assistant).

Prior authorization requirements:

• The CDRP Palivizumab (Synagis®) Prescriber Worksheet and Instructions provides step-by-step assistance in completing the prior authorization process.
• To obtain prior authorization for Synagis®, the prescriber or authorized agent must contact the clinical call center at 1-877-309-9493, follow the appropriate prompts and be prepared to provide justification for use outside of the American Academy of Pediatrics guidelines and FDA approved indications.

The Centers for Disease Control and Prevention (CDC) collects weekly RSV virology data from participating laboratories using the National Respiratory and Enteric Viruses Surveillance System (NREVSS). State-level RSV data are available at http://www.cdc.gov/surveillance/nrevss/rsv/state.html.

Based on data from previous years, the Department of Health recognizes the RSV season as October 16th through March 31st of each season.