Synagis (Palivizumab) is used to help prevent RSV infection in infants and children at high risk. Children's Community Health Plan is working with CVS Caremark for the 2019-2020 season to distribute Synagis to BadgerCare Plus with CCHP and Care4Kids members.
Here is the process:
- Providers should submit the prior authorization request in the CareWeb Qi portal. Here are instructions on how to submit in the portal. Please contact us at 414-266-4522 if you do not have access to the portal.
- CCHP's Utilization Management team will review the prior authorization request and notify the provider if Synagis is approved or denied. The parent or guardian will, also, be notified if it is denied.
- Once approved, the provider will need to fax this form to CVS Caremark. Please include a fax cover sheet with the authorization approval number. Care4Kids Members:
- Please indicate on the form if the patient is a Care4Kids member.
- CVS Caremark will only reach out to the provider for a Care4Kids member.
- CVS Caremark will contact the BadgerCare Plus member's family if Synagis is approved. CVS will attempt three times to reach the parent for delivery. If unable to reach either, the case will be closed out 48 hours later and lost to contact letters will be sent out.
- CVS Caremark will then reach out to the provider to set up the delivery date.
- Upon delivery, the provider will receive a refill form that will need to be sent back to CVS Caremark for the future doses.
Prescribing providers and billing providers may amend approved prior authorizations for Synagis if a member's weight changes, resulting in an increase in Synagis units during a treatment season.
- Providers have 30 days from the date of administering each dose change to amend an approved prior authorization.
- A maximum of five doses of Synagis will be approved. Fewer than five monthly doses will be needed for children born during the RSV season.
- Prior authorization is available for both the 100mg and 50mg vial.
If you have questions about this process, please contact the Healthy Mom, Healthy Baby team at 414-337-BABY (2229).