Prior authorization form and coverage criteria — RSV prophylaxis (palivizumab/Synagis)
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Provider-completed prior authorization form and clinical criteria for monoclonal antibody RSV prophylaxis (palivizumab/Synagis) with guidance on PA submission, documentation, and eligibility for Medicaid populations served by the payer.
No material clinical or coverage changes in this revision.
Coverage Criteria for RSV Prophylaxis (palivizumab / Synagis)
Initial Synagis eligibility
Approved for a maximum of five doses when ANY of the following high-risk conditions are met for patients meeting age/weight criteria
Synagis approval criteria
- Prematurity - very preterm: Member was born before 29 weeks 0 days' gestation.
- Prematurity with chronic lung disease: Member was born before 32 weeks 0 days' gestation AND has chronic lung disease necessitating >21% oxygen for at least the first 28 days of life (provide dates of oxygen supplementation/medication intervention).
- Hemodynamically significant heart disease: Member has hemodynamically significant heart disease (for example, acyanotic heart disease receiving medication to control congestive heart failure and will require cardiac surgical procedures, or moderate to severe pulmonary hypertension). Provide relevant diagnoses/medical intervention.
- Congenital airway or neuromuscular disease: Member has a congenital airway abnormality or neuromuscular disease that impairs the ability to clear secretions. Provide relevant diagnoses/medication intervention.
- Cystic fibrosis with clinical compromise: Member has cystic fibrosis with clinical evidence of chronic lung disease and/or nutritional compromise.
- Profound immunocompromise: Member is or will be considered to be profoundly immunocompromised during the RSV season (must provide chart documentation and explicitly state how member is or will be profoundly immunocompromised), including members undergoing cardiac transplantation during the current RSV season. Please explain and provide documentation.
Second-season Synagis eligibility
For members approaching a second RSV season or older infants, additional criteria may be required
Second season / continued therapy
- Prematurity with ongoing respiratory support: Member was born before 32 weeks 0 days' gestation, required at least 28 days of supplemental oxygen after birth, and continued to require supplemental oxygen, chronic systemic corticosteroid therapy, diuretic, or bronchodilator therapy within 6 months of the start of the second RSV season. Provide dates of oxygen supplementation/medication intervention.
- Cystic fibrosis with severe disease or poor growth: Member has cystic fibrosis with manifestations of severe lung disease (previous hospitalization for pulmonary exacerbation in the first year of life or persistent abnormalities on chest imaging when stable) OR weight-for-length < 10th percentile. Provide relevant diagnoses/medical intervention.
Prescriber must attest that the member has not received Beyfortus (nirsevimab) within the same RSV season. Prior receipt of Beyfortus during the season excludes coverage of Synagis (palivizumab) for that season until the prescriber provides the required attestation on the PA form. The PA form includes a prescriber signature line to confirm this attestation.
Key Clinical Coding & Eligibility Definitions
Provider Requirements and Prior Authorization Process
Submit PA form via fax to Prior Authorization of Benefits Center
Complete and fax the provider-completed PA form to the Prior Authorization of Benefits Center at 844-864-7860 for retail services or 888-209-7838 for medical injectable services to request prior authorization.
Provide medical justification and attestation for Synagis over Beyfortus
If requesting palivizumab (Synagis) instead of Beyfortus (nirsevimab), the prescriber must submit valid medical justification on the PA form and attest whether Beyfortus has not been received in the same RSV season.
- Include written medical justification in the designated section of the form (item 4).
- Sign the attestation that the member has not received Beyfortus in the same RSV season (item 5).
Complete required PA form fields and supporting clinical documentation
Complete the PA form fields requested: patient identifiers, prescriber information, requested medication and dosing, and clinical details relevant to eligibility; include the medical justification section when requesting Synagis over Beyfortus and the prescriber attestation regarding prior Beyfortus receipt.
- Patient: Medicaid number, date of birth, patient name.
- Prescriber: name, Indiana license number, specialty, NPI, signature and return contact info.
- Medication: requested medication name, strength, dosage regimen.
- Clinical details: gestational age, current age and weight, dates of oxygen supplementation/medication interventions, diagnoses/interventions, and chart documentation for profound immunocompromise if applicable.
- If applicable, include medical justification for Synagis over Beyfortus and the attestation that Beyfortus was not received this RSV season.
Ensure the PA form is fully completed or request will be returned
All sections of the PA form must be completed; incomplete or partially completed forms will be returned and the request will not be processed.
- The form must be completed by the prescribing provider and include the required prescriber signature in the attestation section.
- Mark the retroactive PA box and provide dates of service when applicable; submit retroactive requests separately per form instructions.
Background
This PA form supports prophylactic use of monoclonal antibodies for respiratory syncytial virus (RSV) in high‑risk infants and young children. It documents clinical eligibility elements (for example, prematurity with specific gestational-age thresholds and oxygen/medication requirements, cystic fibrosis with severe lung disease, and other high‑risk conditions), requires prescriber justification when requesting Synagis over Beyfortus, and limits prophylaxis to a maximum of five doses or until the end of the RSV season, whichever comes first. The form also defines the RSV season as November 1 through March 31 and notes the Office of Medicaid Policy & Planning may extend the season based on statewide virology data.
Operational Definitions
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