Effective October 1, 2023, due to the increased prevalence of Respiratory Syncytial Virus (RSV), providers may submit prior approval requests for Synagis (palivizumab). This applies to customers covered under Medicaid fee-for-service or a managed care plan. Providers should contact the appropriate managed care plan for approval guidance. For fee-for-service customers, providers must complete the Drug Authorization Request Form for Synagis and fax it to the Pharmacy Unit at 217-524-7264. Approval for the early dosing will be provided for those customers who meet the Department’s Synagis Prior Approval Criteria.
For both fee-for-service and managed care customers, the approval period for the dose will be effective through February 29, 2024. The Department will continue to monitor for necessary changes. This is a temporary deviation from the usual Synagis guidelines, and the Department will continue to monitor RSV prevalence and respond accordingly.
Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565, or to the appropriate managed care plan.
Also in Illinois, the Department of Healthcare and Family Services (HFS) is notifying all pharmacies of billing instructions for the new commercial COVID-19 vaccines now in circulation. These instructions apply to the fee-for-service program only.
As HFS is still finalizing programming for the administration fee for the COVID vaccine, pharmacies cannot use “MA” in the Professional Service Code Field, nor add the administration fee until the new programming is complete. Pharmacies can still provide COVID-19 vaccinations and submit claims to HFS for reimbursement for the cost of the vaccination plus a dispensing fee as they would for other vaccinations that do not pay an administration fee.
Once the programming is complete, pharmacies can then void and rebill for services rendered to receive the full payment including the applicable administration fee.
A provider notice will be sent to pharmacies once programming is complete and pharmacies can bill for the administration fee. The void and rebill process to receive full payment for claims that were submitted without receiving the administration fee can commence at that time.
Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565.
For more information, contact NACDS’ Leigh Knotts at 803-243-7207.