RSV Synagis 2022-2023

Date: 11/29/22

AzCH-CCP has been closely monitoring Respiratory Syncytial Virus (RSV) activity in Arizona and acknowledges we are experiencing an unprecedented RSV Season. Passive prophylactic immunization with Synagis® continues to be the standard of care for RSV in children most vulnerable to severe infection. To make sure patients who are at high risk for RSV infection receive appropriate care, we have removed the prior authorization requirements for Synagis this season for children under the age of two years old that meet the medical necessity criteria. The prior auth change is for our Medicaid members only; it does not pertain to Ambetter. Prior authorization is still required for members two years and older.

The Synagis® Prior Authorization Criteria and the AzCH-CCP RSV (Synagis®) Prior Authorization Form are available here on the AzCH-CCP website on the RSV/Synagis Season page.

A maximum of 5 doses during the RSV season will be authorized. AzCH-CCP will continue to monitor RSV state trends throughout the year and will approve additional doses when medically necessary. Synagis® is available through a limited distribution network as established by the manufacturer. To obtain prior authorization:

• Submit your RSV prior authorization request electronically through our preferred solution

Cover My Meds OR complete the RSV Prior Authorization Form available on our website and submit via FAX to 1-883-546-1508

• The following pharmacies are available to dispense Synagis®, which will be shipped directly to your office* to be administered to the member.

o AcariaHealth (FAX: 1-877-252-2444) OR

• Please bill administration charges (CPT codes) for Synagis® directly to AzCH-CCP

Please contact Pharmacy Prior Authorization at 1-888-788-4408 x 6031278 if you have any questions.

Thank you!