Point32Health would like to remind providers of our policy regarding Synagis (palivizumab), an injection of antibodies used to protect high-risk infants from severe respiratory syncytial virus (RSV) disease, for the 2024-2025 season.
Synagis requires prior authorization and should be reserved for infants with a history of pre-term birth and children with chronic lung disease or congenital heart disease. For members who qualify to receive five doses, the first dose is typically administered at the beginning of November and the last dose at the beginning of March to provide protection into April.
Requesting authorization
Point32Health manages prior authorization for medical drugs, including Synagis. Refer to the Synagis Medical Necessity Guidelines in the Medical Benefit Drug Medical Necessity Guidelines section of our provider website for clinical coverage criteria. Prescribing providers should request authorization for Synagis via PromptPA, which you can access directly or through the Harvard Pilgrim or Tufts Health Plan provider portals, or by fax.
Online submission will enable you to easily view drug specific criteria questions, attach clinical information, and receive a response more quickly.
For Harvard Pilgrim Commercial, Tufts Health Plan Commercial, and Tufts Health Direct, providers can also obtain Synagis from CVS Caremark for authorized members, and members are responsible for their appropriate cost share. If any of your patients have questions about their cost share for Synagis, please direct them to the Harvard Pilgrim or Tufts Health Plan Member Services phone number on the back of their ID card.
As a reminder, for Tufts Health Together, coverage and criteria for Synagis are available through the MassHealth Drug List.
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