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 March. 

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, or if Synagis will be ordered and shipped from the BCBSKS preferred pharmacy vendor, Prime Specialty Pharmacy, please use this prior authorization request.

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