MedicaidPrior AuthMedium impact
[Ohio] Newborn RSV Prevention
CareSource·OH · Pediatrics, OB-GYN, Family Medicine +1 more·Provider Bulletin
Effective date
Oct 15, 2025
We identified it
May 9, 2026
Summary
CareSource Ohio Medicaid is notifying providers of RSV prevention options for newborns and pregnant individuals, including updated prior authorization requirements. Synagis (Palivizumab) will be discontinued December 31, 2025, and providers must attest to adequate stock when requesting prior authorization. Abrysvo and Beyfortus have no medical prior authorization requirements but are subject to SPBM carve-out pharmacy prior authorization.
Action Required
By December 31, 2025: Billing team must update prior authorization workflows to discontinue processing Synagis (Palivizumab) claims. Any Synagis requests submitted before this date require provider attestation of adequate office stock to cover the member through RSV season. Immediately: Verify that billing system does NOT require medical prior authorization for Abrysvo or Beyfortus (Nirsevimab), as these are SPBM carve-out medications requiring only pharmacy prior authorization. For Synagis claims submitted through December 31, 2025, ensure prior authorization requests include provider attestation documentation. Update encounter forms and EMR templates to reflect RSV prevention options and discontinuation timeline. Contact CareSource Health Partner Services at 1-800-488-0134 for clarification on any Synagis stock verification requirements. Failure to properly handle the Synagis discontinuation may result in claim denials after December 31, 2025.