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NYS Medicaid Pharmacy Prior Authorization Programs

Providers • CDRP • Drugs • palivizumab (Synagis®)

Palivizumab (Synagis®)

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

Prior Authorization for Synagis® has been implemented to reinforce appropriate use and to ensure utilization consistent with the approved indications. Only prescribers, not their authorized agents, can initiate the prior authorization 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.

The following is general information about Palivizumab (Synagis®) prior authorization requirements:

On September 15, 2009, Synagis® was added to the Clinical Drug Review Program (CDRP). The goal of the program is 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 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 (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

To access the most current CDRP instructions and worksheets, please visit: https://newyork.fhsc.com/providers/CDRP_forms.asp

For clinical concerns or CDRP questions, please call (877) 309-9493.

For billing questions, please call (800) 343-9000.

For Medicaid pharmacy policy and operation questions, please call (518) 486-3209.