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NYS Medicaid Pharmacy Prior Authorization Programs

palivizumab (Synagis®)

Palivizumab (Synagis®)

Prior Authorization Call Line: 1-877-309-9493

Prior Authorization for Synagis® has been implemented 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). Fax requests are not permitted.

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 must contact the clinical call center at 1-877-309-9493 and follow the appropriate prompts. Prescribers should be prepared to discuss their justification for use outside of the American Academy of Pediatrics guidelines and FDA approved indications.

For clinical information on bronchiolitis and use of Synagis®, please visit the Prescriber Education program website at http://www.nyhealth.gov/health_care/medicaid/program/prescriber_education/presc-educationprog