01Already effective October 1, 2025: Submit Synagis PARs using the most appropriate process.
02Pharmacy benefit PARs for Synagis administered in the home or at a long-term care facility go to Prime Therapeutics, faxed at 800-434-5881 on the Synagis PAR Form, and must be signed by the prescribing physician even when submitted by a home health agency or long-term care facility.
03Medical benefit PARs for Synagis administered in a doctor's office, hospital or clinician's office go to Acentra Health's Atrezzo portal, and the units requested are the number of 50-mg units needed per dose, using CPT code 90378.
04On professional or institutional claims for Synagis given in an office or outpatient setting, use CPT code 90378 and the NDC of the medication administered, billed in one-unit increments of 50 mg, through the Provider Web Portal or the 837P transaction.
05Providers may not ask members to obtain Synagis from a pharmacy and take it to the practitioner's office for administration.
06Pharmacy claims are limited to one 50-mg vial per 26-day period.
07Home administration of Synagis is limited to members approved for home health, the home health agency bills for administration and not for Synagis, and these visits cannot exceed five standard RN visits.
08For nirsevimab, bill CPT 90380 or 90381 with administration code 96380 or 96381.
09For clesrovimab, bill CPT 90382 with administration code 96380 or 96381.
10Do not report immunization administration codes 90461-90462 or 90471-90472 for the injection of nirsevimab or clesrovimab.
11Providers must enroll in the Vaccines for Children program to receive these long-acting monoclonal antibody products and to receive reimbursement for administering them.
12For vaccine counseling visits, bill CPT G0310, G0311, G0312, G0313, G0314 or G0315 once per member per day, include modifier CR for COVID-19 vaccine counseling-only visits, keep documentation of the counseling duration and the prevention topics covered, and report a separate E/M visit with modifier 25 only when there is a separately identifiable E/M service.
13Requests for Synagis that do not meet the AAP indications will be denied, and members may appeal through the normal member appeal process.