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Elizabeth M. Whitehorn, Director

Provider Notice issued 03/01/2024

 

To:
 Enrolled Physicians; Advanced Practice Nurses: Physician Assistants; Local Health Departments; Hospitals; Federally Qualified Health Centers; Rural Health Clinics; Encounter Rate Clinics; and Pharmacies
​Date: ​March 1, 2024
​Re: Coverage for Synagis Extended through March 31, 2024

This notice serves to inform providers that, due to the continued prevalence of Respiratory Syncytial Virus (RSV), the Department of Healthcare and Family Services (HFS) is extending its coverage for Synagis (palivizumab) through March 31, 2024. This applies to customers covered under Medicaid fee-for-service (FFS) or a managed care plan. Providers should contact the appropriate managed care plan for approval guidance. 

Due to the security breach and subsequent system outage at Change Healthcare, HFS’ Pharmacy Benefits Management System (PBMS) for the FFS program, providers are unable to obtain prior approval. Providers billing on the 837 Professional claim format may submit their claims for Synagis without prior approval. Pharmacies are encouraged, in good faith, to continue to provide this medication as needed. Once the system is operational, HFS will make pharmacies whole and assist with claim submissions and provide any necessary overrides.

Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565, or the appropriate managed care plan.

 

Kelly Cunningham, Administrator

Division of Medical Programs