MedicaidPrior AuthMedium impact
Synagis® (palivizumab) (Revised)
Humana·SC · Pediatrics, Pulmonology, Cardiology·Medicaid
Effective date
Jul 1, 2024
We identified it
Jun 24, 2026
Summary
Humana Medicaid South Carolina has updated their prior authorization policy for Synagis (palivizumab) injections used to prevent RSV in high-risk infants and children. The policy clarifies coverage criteria for premature infants, those with bronchopulmonary dysplasia, and congenital heart disease patients, with approvals lasting 6 months.
Action Required
Immediately: Billing team must verify prior authorization requirements for all Synagis (palivizumab) injections for Humana Medicaid South Carolina members. Ensure documentation includes patient age, gestational age at birth, and specific diagnosis (prematurity ≤35 weeks, bronchopulmonary dysplasia with treatment in past 6 months, or hemodynamically significant congenital heart disease). Submit prior auth requests with 6-month approval durations. Claims will be denied without proper prior authorization.