MedicaidPrior AuthMedium impact
Authorization for Palivizumab (Synagis)
Connecticut Medicaid (HUSKY Health)·CT · Pediatrics, Pulmonology, Cardiology +1 more·Prior Authorization
Effective date
Feb 1, 2017
We identified it
Jun 20, 2026
Summary
Connecticut Medicaid (CMAP) requires prior authorization for Palivizumab (Synagis) RSV prophylaxis in all settings except inpatient hospitals. Providers must use specific PA forms and work with preferred pharmacies or submit hospital outpatient requests directly to HUSKY Health.
Action Required
For Connecticut Medicaid patients needing Synagis: 1) Physicians/APRNs/PAs must complete the Palivizumab Prior Authorization Request Form and fax to preferred CMAP enrolled pharmacies listed on the form. 2) Outpatient hospitals must complete the Synagis Outpatient Hospital Form and fax to 203.774.0549. 3) Obtain PA before scheduled injection date to avoid delivery delays. 4) Use procedure code 90378 for billing. 5) Ensure proper ICD-10 codes are documented per the 6 clinical criteria categories. No PA required for inpatient hospital administration.