New Forms Update: 2018-2019 Palivizumab (Synagis)

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Date: October 25, 2018
To: Health Plan of San Joaquin (HPSJ) Providers and Practitioners
From: HPSJ [Medical Management Department]
Subject: New Forms Update: 2018-2019 Palivizumab (Synagis)
Business: Medi-Cal

The Center of Disease Control and Prevention (CDC) reports that Respiratory syncytial virus (RSV) is known as one of the most common illnesses among infants and children. The American Academy of Pediatrics (AAP) recommends administration of palivizumab (Synagis), to prevent serious RSV illness in qualifying high-risk infants and young children. RSV is usually seasonal which occurs during fall, winter and spring. In the Central Valley, the RSV season is between November 1st through March 31st of every year.

To facilitate access to Palivizumab (Synagis) for Respiratory Syncytial Virus (RSV) for qualifying high risk patients, Health Plan of San Joaquin has provided the following documents:

Please note that Prior Authorization Form in compliance with CCR Title 28 §1300.67.241, HPSJ will only accept and use Form No. 61-211 for pharmacy prior authorization requests. We recommend including Synagis Authorization form 2018-2019 with Form 61-211.

As a reminder, certain underlying conditions may be eligible for CCS Palivizumab (Synagis) coverage. Please see “Synagis Recommendations 2018-21019” for qualifying CCS eligible criteria.

Health Plan of San Joaquin is dedicated to providing all members the best health care available in the most effective and efficient manner. You may contact our Customer Services Department with any questions or concerns, Monday through Friday 8 a.m. to 6 p.m. at (209) 942-6320.

This section of HPSJ’s website is to support Health Plan of San Joaquin providers with important announcements from the California Department of Health Care Services (DHCS), FDA, and HPSJ Pharmacy Department.

Posted on October 25th, 2018 and last modified on September 9th, 2022.