Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111	
	MassHealth
	Pharmacy Bulletin 60
	September 1999

	TO:	Pharmacies Participating in MassHealth

	FROM:	Mark E. Reynolds, Acting Commissioner

	RE:	Obtaining Prior Authorization and Submitting Claims for Synagis (Palivizumab)

Introduction	Synagis (palivizumab) is a medication used to prevent respiratory syncytial virus (RSV) infection in infants and children at increased risk for severe disease, in particular those born prematurely and those with chronic lung disease. 

	To ensure that Synagis is delivered correctly and appropriately to MassHealth members, the Division requires prior authorization before the administration of this drug to its members.  The Division’s criteria for evaluating prior-authorization requests for Synagis are based on the American Academy of Pediatrics guidelines for infants and children at high risk for developing RSV lower respiratory tract infection (attached).  For each infant or child for whom prior authorization is granted, prior authorization will be issued for the duration of the RSV season, that is, the period of time during which RSV is most prevalent, usually from November through April.

Supplying Synagis	The two alternatives for reimbursement from the Division for supplying Synagis are:

		reimbursement to a MassHealth practitioner or community health center supplying Synagis in the office; or

		reimbursement to the MassHealth pharmacy provider if  the pharmacy provider delivers the Synagis to the office of the MassHealth practitioner or the community health center administering the Synagis.

Prior Authorization 	Prior authorization for Synagis supplied by a MassHealth pharmacy who 
Requests	delivers this drug must be requested by the prescribing provider.  The prescribing provider must complete a Request for Prior Authorization form (sample attached) or submit a written request on letterhead containing the information required in the billing instructions in Subchapter 5 of the provider manual.  The request must include the name, address, and telephone number of the pharmacy that will fill the prescription.

										

New Address for Prior-	Effective September 6, 1999, submit all prior-authorization requests for drugs 
Authorization Requests	to the following address:
For Drugs
University of Massachusetts Medical School 
DUR Program Offices
11 Midstate Drive
Auburn, MA 01501
Telephone #:  (508) 721-7171
Fax #:  (508) 721-7138

Obtaining Prior- 	To obtain supplies of the Request for Prior Authorization form, mail or fax
Authorization Forms	a written request to the following address or fax number.

Unisys
Attn: Forms Distribution
P.O. Box 9101
Somerville, MA 02145
Fax: (617) 576-4087

Questions	If you have any questions about the information in this bulletin, please contact the Unisys Provider Services Department at (617) 628-4141 or 
	1-800-325-5231.