MedicaidPrior AuthMedium impact
Authorization for Palivizumab (Synagis®) - 2017-2018 Respiratory Syncytial Virus (RSV) Season pdf
Connecticut Medicaid (HUSKY Health)·CT · Pediatrics, Pulmonology, Cardiology·Prior Authorization
Effective date
Nov 1, 2017
We identified it
Jun 20, 2026
Summary
Connecticut Medicaid (HUSKY Health) requires prior authorization for Palivizumab (Synagis®) RSV prophylaxis for the 2017-2018 season. Different PA processes apply for outpatient hospitals versus physicians/APRNs/PAs, with specific forms required for each setting.
Action Required
By November 1, 2017: Outpatient hospitals must fax completed PA request forms with clinical documentation to CHNCT at 203.774.0549 before administering Synagis® to HUSKY members. Physicians, APRNs, and PAs must fax PA forms to preferred CMAP enrolled pharmacies who will submit to CHNCT. Use appropriate forms available on HUSKY Health website. Contact CHNCT at 1.800.440.5071 for PA questions.