Prior Authorization

Synagis

Synagis is indicated for the prevention of serious lower respiratory tract disease caused by respiratory syncytial virus (RSV) in pediatric patients at high risk. Indications include:

• Children <2 years of age with chronic lung disease (CLD) that have required medical treatment for their CLD within the last six months.
• Infants born at ≤ 28 weeks of gestation may receive prophylaxis if ≤12 months of age at the start of RSV season
• Infants born at 29 through 32 weeks of gestation may receive prophylaxis if ≤6 months of age at the start of RSV season
• Infants born at 33 to 35 weeks of gestation
  • With CLD, on medications or treatment within the past six months or
  • Prophylaxis of infants without CLD should be reserved for only those infants who are at the greatest risk of severe infection
• Children 24 months of age or younger with hemodynamically significant cyanotic and acyanotic congenital heart disease may receive prophylaxis injection of Synagis

Synagis is given once a month during the RSV season, November through April. 

Members: If you have questions or wish to initiate a request for prior authorization, please contact your doctor.

Health care providers: If your practice purchases Synagis and bills BCBSKS, please use this prior authorization request. If Synagis will be ordered and shipped from the BCBSKS preferred pharmacy vendor, Triessent, please use this prior authorization request.

Back to listing