Synagis® Authorization Guidelines

Our Synagis® Authorization Guidelines for the 2016 – 2017 RSV Season were developed based on recommendations of the American Academy of Pediatrics and local Louisiana Healthcare Connections physicians. The Synagis Season is November 1, 2016 through March 31, 2017.

Louisiana Healthcare Connections will again use our PBM, US Script, to process requests for Synagis® for the RSV season. Beginning immediately, all requests for Synagis® should be forwarded to US Script for initial screening to determine if the request meets criteria for coverage. The enrollment form is enclosed. When submitting the request, please include the NICU discharge summary to expedite the review process.

Synagis® is available through a limited distribution network as established by the manufacturer.

Your specialty pharmacy of choice will be responsible for the delivery of the injectable product and the overall coordination of the drug distribution process. All injectable products will be billed directly to Louisiana Healthcare Connections by the specialty pharmacy provider and shipped to your office. Administration charges for the injection should be billed directly to Louisiana Healthcare Connections on a (HCFA) CMS 1500 claim form using CPT code 90471. You can also bill for an appropriate office visit for each administration of the drug.

Billing and payment for pre-approved Synagis® administration, outside of your specialty pharmacy provider, requires submission of a claim form using the designated CPT 90378 for Synagis®, with a required NDC and entry of billing units incremental to each 50 mg dose administered (i.e. 100mg = 2 billing units).

To submit your request, fax the completed enrollment form to US Script at 1-866-399-0929. For questions, contact the Louisiana Healthcare Connections Pharmacy Department at 1-866-595-8133.

Download the Synagis® Authorization Guidelines and Referral Form (2016 – 2017 RSV Season).