MedicaidPrior AuthMedium impact
Authorization for Palivizumab (Synagis®) - 2018-2019 Respiratory Syncytial Virus (RSV) Season pdf
Connecticut Medicaid (HUSKY Health)·CT · Pediatrics, Pulmonology, Cardiology·Prior Authorization
Effective date
Nov 1, 2018
We identified it
Jun 20, 2026
Summary
Connecticut HUSKY Health requires prior authorization for Synagis (palivizumab) RSV prophylaxis for the 2018-2019 season when provided in outpatient settings. No changes to medical necessity criteria, but specific PA forms must be completed and faxed to designated pharmacies or CHNCT.
Action Required
For 2018-2019 RSV season (Nov 1, 2018 - March 31, 2019): Providers treating HUSKY Health members must complete appropriate Synagis PA forms before administering outpatient doses. Hospitals must fax PA requests to CHNCT at (203) 774-0549. Physicians/APRNs/PAs must fax PA requests to preferred CMAP enrolled pharmacies (CVS/Caremark or Walgreens) who then submit to CHNCT. Download forms from www.ct.gov/husky under Provider Forms. Failure to obtain PA will result in claim denials.