Prior Authorization Requests for Synagis and the Respiratory Syncytial Virus Season Effective September 22, 2022

Due to an increase in respiratory syncytial virus (RSV) virology in Wisconsin, ForwardHealth is accepting prior authorization (PA) requests for Synagis effective September 22, 2022. Synagis (palivizumab), a monoclonal antibody, is used as a prophylaxis to reduce lower respiratory tract disease caused by RSV in premature, high-risk infants and children.

PA requests for Synagis may be submitted via the ForwardHealth Portal for real-time PA review and approval beginning October 1, 2022.

Prescribers or their designees, not pharmacy providers, are required to submit PA requests for Synagis. Synagis administered in a hospital does not require PA.

In addition, ForwardHealth is also moving the RSV season start date for providers to begin administering and dispensing Synagis doses for BadgerCare Plus and Medicaid members when clinically appropriate for dates of service (DOS) on and after September 22, 2022. For the 2022–2023 RSV season, ForwardHealth coverage criteria for approved Synagis PA requests submitted for DOS between September 22, 2022, and October 31, 2022, will allow a maximum of six Synagis doses per member. Approved Synagis PA requests submitted for DOS between November 1, 2022, and December 31, 2022, will allow a maximum of five Synagis doses per member, per the current ForwardHealth coverage criteria for Synagis.

Note: Prescribers who are submitting PA requests via the Portal may request six Synagis doses on the PA request if the effective DOS is between October 1, 2022, and October 31, 2022.

The change in this RSV season’s start date for Synagis PA submission and Synagis administration or dispensing is only for the 2022–2023 RSV season.

For more information about current PA policy for Synagis, providers may refer to the Synagis topic (#7877) in the ForwardHealth Online Handbook.