Coverage of Synagis for the 2014/2015 Season

The N.C. Medicaid outpatient pharmacy benefit will cover Synagis for the upcoming Respiratory Syncytial Virus (RSV) season based on the updated guidance from the American Academy of Pediatrics (AAP) Committee on Infectious Diseases and the Bronchiolitis Guidelines Committee. The AAP guidance, published online on July 28, 2014 (see link below), replaces the 2012 Red Book recommendations. The updated guidelines narrow the criteria for evidence-based use of Synagis.

The only method to submit a prior authorization (PA) request for coverage of Synagis for administration during the time period of November 1, 2014, to March 31, 2015, is through Document For Safety. (See link below.) Registration is required to access the web-based program found there. The start date for PA request submission is October 17, 2014. The first payable date of service for the 2014/2015 season for a pharmacy point of sale claim for Synagis is October 28, 2014. Medicaid will review the coverage quantity for a Synagis dose authorization when the request is made by the prescribing provider.

Provider support for the Synagis program is available at 855-272-6576.