2020-2021 RSV Season

Criteria for Reimbursement of Palivizumab (Synagis®) Special Dosing Considerations [July 2021-October 2021] (Medicaid Provider)

Prior Authorization Request Coversheet and Palivizumab (Synagis®) Clinical Authorization Form for Special Dosing Considerations [July 2021-October 2021]

2018-2019 RSV Season

Criteria for Reimbursement of Palivizumab (Synagis ®) for 2018-2019 RSV Season (Medicaid Provider) 09/01/18

Palivizumab Clinical Pre-Authorization Form 10/31/18

Palivizumab Request for Reconsideration 10/31/18

2017-2018 RSV Season

Criteria for Reimbursement of Palivizumab (Synagis ®) for 2017-2018 RSV Season (Medicaid Provider) 10/01/17

Palivizumab Clinical Pre-Authorization Form 10/01/17

Palivizumab Request for Reconsideration 10/01/17

2016-2017 RSV Season

Criteria for Reimbursement of Palivizumab (Synagis ®) for 2016-2017 RSV Season for Fee-for-Service (FFS) Medicaid Recipients (Medicaid Provider) 10/01/16

Palivizumab Clinical Pre-Authorization Form 10/01/16

Palivizumab Request for Reconsideration 10/01/16

2015-2016 RSV Season

Criteria for Reimbursement of Palivizumab (Synagis ®) for 2015-16 RSV Season (Medicaid Provider) 10/15/15

Palivizumab Clinical Pre-Authorization Form 10/15/15

Palivizumab Request for Reconsideration 10/15/15

2014-2015 RSV Season

Criteria for Reimbursement of Palivizumab (Synagis®) for 2014-15 RSV Season (Medicaid Provider) 10/20/14

Palivizumab Clinical Pre-Authorization Form 10/20/14

Palivizumab Request for Reconsideration 10/20/14

2013-2014 RSV Season

Criteria for Reimbursement of Palivizumab (Synagis ®) for 2013-14 RSV Season (Medicaid Provider) 10/8/13

Request for Reconsideration 10/08/12

Palivizumab Override Authorization Request 10/01/12

2012-2013 RSV Season

Criteria for Reimbursement of Palivizumab (Synagis®)for 2012-13 RSV Season (Home Health) 4/3/13

Criteria for Reimbursement of Palivizumab (Synagis®)for 2012-13 RSV Season (Pharmacist) 4/3/13

Criteria for Reimbursement of Palivizumab (Synagis®)for 2012-13 RSV Season (Prescribing Practitioner) 4/3/13

2011-2012 RSV Season

Criteria for Reimbursement of Palivizumab (Synagis®) for the 2011-2012 RSV Season - Pharmacists< 9/2/11

Criteria for Reimbursement of Palivizumab (Synagis®) for the 2011-2012 RSV Season – Prescribing Practitioners 10/6/11

Criteria for Reimbursement of Palivizumab (Synagis®) for the 2011-2012 RSV Season – Home Health Providers 10/6/11

2010-2011 RSV Season

Criteria for Reimbursement of Palivizumab (Synagis®) for the 2010-2011 RSV Season - Pharmacists 9/16/10

Criteria for Reimbursement of Palivizumab (Synagis®) for the 2010-2011 RSV Season – Prescribing Providers 9/16/10

2009-2010 RSV Season

Prescribing Practitioner Update to Reimbursement Criteria for Palivizumab (Synagis) Letter 3/18/10

Pharmacist Update to Reimbursement Criteria for Palivimab (Synagis) Letter 3/18/10

Criteria for Reimbursement of Synagis®, Antipsychotic Agents, and Agents Used to Treat ADD - Prescribing Providers Effective October 1, 2009

Criteria for Reimbursement of Synagis®, Antipsychotic Agents, and Agents Used to Treat ADD - Pharmacists Effective October 1, 2009