Respiratory Syncytial Virus (RSV) Season

August 21, 2010

Dear Peach State Health Plan Clinician,

Please click the link below to review  the Peach State Health Plan (Peach State) Synagis^® Authorization Guidelines for the 2010-2011 RSV season.  These guidelines were developed based on recommendations of the American Academy of Pediatrics (AAP) and local Georgia physicians.

The following modifications have been made to the AAP guidelines for infants born between 32 weeks, 0 days through 34 weeks, 6 days:

• Must be younger than 3 months of age at the start of the RSV season or born during the RSV season, and
• Must either attend child care or have a sibling younger than 5 years of age.
• If patient meets above criteria, Synagis should only be given until the infant reaches 3 months of age.

 Peach State will again use Caremark as its preferred provider of Synagis for the 2010-2011 RSV season. Beginning immediately, all requests for Synagis should be forwarded to Caremark for initial screening to determine if the request meets criteria for coverage. A copy of the Caremark RSV enrollment form can be obtained by clicking the appropriate link below or in the Pharmacy forms section of the website. When submitting the enrollment form, please attach the NICU discharge summary to expedite the review process. 

Caremark will be responsible for the delivery of the injectable product and the overall coordination of the drug distribution process. All injectable products will be billed directly to Peach State by Caremark and shipped to your office.  Administration charges for the injection should be billed directly to Peach State on a (HCFA) CMS 1500 claim form using CPT code 96372. You can also bill for an appropriate office visit for each administration of the drug. 

Caremark specializes in specialty injectables and can provide the support and follow-up with Peach State members to ensure compliance and positive clinical outcomes. Caremark offers:

• 24-hour access to the Caremark case management team
• Patient education and compliance monitoring programs
• Direct refill and renewal coordination
• Approved clinical protocols and treatment guidelines
• Synagis approval for the entire RSV season

 For RSV enrollment, please call 1-800-237-2767, or fax a completed Caremark RSV enrollment form prior authorization request form to 1-800-323-2445.  For additional questions, contact the Peach State Pharmacy Department at 1-800-514-0083 option 2. 

 Thank you for your cooperation,

 Dean Greeson, M.D.

Vice President, Medical Affairs

Enclosures:

• Synagis 2010-2011 Authorization Guidelines (PDF)
• Synagis Administration Policy 2010-2011 season
• Respiratory Syncytial Virus _ Enrollment Form (PDF)

This entry is filed under Blog, News.