Synagis® (palivizumab)

No prior authorization required for:

  • Emergency room
  • Inpatient
  • Skilled nursing facility

Injectable auth/billing notes:

Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.

Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.

Code(s): 90378

Benefit: Medical

Notes: Immune globulin for respiratory syncytial virus (RSV)                             

Criteria for coverage:

  • See PA form for criteria for Commercial and Medicaid

  • Not covered for Medicare