MedicaidPrior AuthMedium impact
Synagis Policy Statement RSV Season 2015-2016
Georgia Medicaid·GA · Pediatrics, Pulmonology, Cardiology·Pharmacy
Effective date
Oct 1, 2015
We identified it
Jun 20, 2026
Summary
Georgia Medicaid has updated its policy for Synagis (palivizumab) RSV prophylaxis for the 2015-2016 season, establishing specific eligibility criteria and dosing limits for high-risk infants. The policy allows up to 5 doses per season for qualifying patients and requires prior authorization through OptumRx starting September 21, 2015.
Action Required
By September 21, 2015: Billing team must begin submitting Synagis prior authorizations to OptumRx at 1-888-491-9742 using the updated PA Request Form with ICD-10 codes only. Providers must review eligibility criteria and dosing schedule table to ensure appropriate prescribing. Update systems to track maximum allowable doses based on start month (5 doses if started in October, decreasing monthly). Only original physician signatures will be accepted on requests.