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Prior Authorization

Prior Authorization Request Services and Forms

Synagis/Respigam

Synagis and Respigam are covered by the South Dakota Medical Assistance Program starting November 1st of each calendar year through March 31st of the following calendar year when a child meets all of the following criteria:

  • the medication has been prior authorized by the Department of Social Services/Medical Assistance;
  • it has been recommended by a Neonatologist, Pediatric Pulmonologist, or Pediatric Cardiologist; and
  • the child meets one of the following categories listed below:
  1. Children under 6 months of age at the onset of the RSV season who were 32 weeks and less gestational age at birth.
  2. Children under 3 months of age at the onset of the RSV season or who are born during the RSV season (11/1/2012-3/31/2013) who were between 32 and 35 weeks gestational age at birth with one of these 2 risk factors: day care attendance or a sibling in the household less than 5 years of age.
  3. Children under two years of age at the onset of the RSV season with evidence of ongoing lung disease such as bronchopulmonary dysplasia or cystic fibrosis requiring treatment with oral bronchodilators, supplemental oxygen, diuretics, or nebulized or inhaled medications to stabilize the disease in the last 6 months.
  4. Children under two years of age at the onset of the RSV season with evidence of hemodynamically significant cyanotic or acyanotic congenital heart disease and one of the following:  receiving medication to control congestive heart failure, moderate to severe pulmonary hypertension, or undergoing surgical procedures that use cardiopulmonary bypass.
  5. Children under two years of age at the onset of the RSV season with immunodeficiencies that may make them more susceptible to severe lower respiratory tract disease related to RSV.
  6. Any child under two years of age at the onset of the RSV season felt to be at high risk for significant lower respiratory tract illness related to RSV.
  • Billing Instructions: Physicians Office
  • Form: CMS 1500
  • Procedure Code: 90378
  • Rate of Payment: Synagis is reimbursed at the rate specified on the Physician Services fee schedule.

Mail or fax prior authorization request form and documentation to:

Western South Dakota Eastern South Dakota
  • Division of Medical Services
    Nurse Consultant
    510 N Campbell, PO Box 2440
    Rapid City, SD 57709
  • Phone: 605-394-1740
  • Fax: 605-394-2699
  • Division of Medical Services
    Nurse Consultant
    811 E. 10th Street Dept. 8
    Sioux Falls, SD 57103-1650
  • Phone: (605) 367-7601
  • Fax: (605) 367-5253