CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Synagis (palivizumab) prior authorization and medical necessity/order form

This document is the New Mexico prior authorization/statement of medical necessity/order form and instructions for Synagis (palivizumab) covering eligibility criteria, prescription orders, and payer-specific submission details for providers and caregivers seeking coverage and dispensing for infants and young children.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicySynagis (palivizumab) prior authorization and medical necessity/order form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must complete the New Mexico Synagis PA/Statement of Medical Necessity/Order Form with one circled eligibility category and supporting documentation and submit it for prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7eligibility categories

2vial NDCs

15 mg/kgdose

28 daysinterval

Coverage Criteria for Synagis (palivizumab)

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicySynagis (palivizumab) prior authorization and medical necessity/order form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

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Eligibility categories

1: <12 months old (as of November 15) with hemodynamically significant congenital heart disease (CHD)age <12 months as of Nov 15
See form criterion 1
2a: <12 months old (as of November 15), <32 weeks 0 days gestation with chronic lung disease (CLD) of prematurity requiring oxygen (FiO2 >21%) for >28 days after birthage <12 months as of Nov 15; gestational age <32 wks; oxygen requirement >28 days
See form criterion 2(a)
2b: <24 months with chronic lung disease (CLD) and continues on supplemental oxygen, diuretic or corticosteroidage <24 months as of Nov 15; ongoing therapy (oxygen, diuretic, or corticosteroid)
See form criterion 2(b)
3: <24 months old (as of November 15) with severe immunodeficiency (specify type)age <24 months as of Nov 15; documented severe immunodeficiency
See form criterion 3
4: <12 months old (as of November 15) with severe neuromuscular disease with inability to clear secretionsage <12 months as of Nov 15; inability to clear secretions
See form criterion 4
5: <12 months old (as of November 15) with congenital abnormality of the airway with inability to clear secretionsage <12 months as of Nov 15; airway abnormality with impaired secretion clearance
See form criterion 5
6: <12 months old (as of November 15) and born at 28 weeks, 6 days gestation or lessgestational age ≤28 wks 6 days; age <12 months as of Nov 15
See form criterion 6
7: <24 months old (as of November 15) and will undergo cardiac transplantation during the RSV seasonplanned cardiac transplant during RSV season; age <24 months as of Nov 15
See form criterion 7

Payer-specific submission requirement: Blue Cross Blue Shield (BCBS) - New Mexico no longer accepts the New Mexico Prior Authorization/Statement of Medical Necessity (NMPS) form for commercial patients. Commercial members must use BCBS’s predetermine_request form (available at www.bcbsnm.com/pdf/forms/predetermine_request.pdf) and submit it to the BCBS commercial fax number 505-816-3857 or call 800-325-8334 for intake. After authorization, providers must contact the designated specialty pharmacy (AllianceRXWP) to complete the AllianceRXWP Synagis SMN form for dispensing.

Provider Submission, Ordering, and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Submit the completed New Mexico Synagis Prior Authorization/Statement of Medical Necessity/Order Form (NM Synagis PA/SMN form). Use the payer-specific fax numbers or intake phone numbers below for submission. After BCBS NM approval, providers must contact the specialty pharmacy to complete the AllianceRXWP Synagis SMN form for dispensing.

BCBS NM Centennial: fax completed form to 505-816-3854 or call intake 877-232-5518 (when prompted, select option #2). Customer service Centennial: Corinne Kenny, RN, 505-816-2893.
BCBS NM Commercial: download form at www.bcbsnm.com/pdf/forms/predetermine_request.pdf then fax completed form to 505-816-3857 or call 800-325-8334. NOTE: BCBS no longer accepts the NMPS form for commercial patients.
BCBS NM Specialty Pharmacy (after PA approval): AllianceRXWP — call 877-627-6637 or fax 877-828-3939.
Western Sky Community Care: fax completed form to 833-395-5940; Program Coordinator Valerie LaCour call 844-543-8996 ext. 8095049 or email Valerie.LaCour@westernskycommunitycare.com. Specialty Pharmacy: AcariaHealth — call 844-Synagis (844-796-2447) or fax 877-252-2444.
Presbyterian: fax completed form to 505-923-5540 or 800-724-6953. Coordinator Antoinette Vigil call 505-923-5632.
United Healthcare: No PA required; commercial fax 866-940-7328. Specialty Pharmacy: Briova — call 855-427-4682 or fax 877-342-4596.
Medicaid FFS: fax 505-827-7277. Contact FFS Pharmacist: 505-827-3174. Specialty pharmacies: all FFS contracted Specialty Pharmacies. For home health: Qualis Portal or call 866-962-2180. NMPS contact: Pawitta Kasemsap 505-620-8109 or pawitta.kasemsap@davitamedicalgroup.com.
For patient financial assistance and coordination: SOBI Synagis CONNECT 1-866-285-8419 or https://synagisconnect.com/.

Denial Risk

Form Decision / Authorization Outcome

The PA/Order form includes explicit authorization outcome fields. The completed form must include the practitioner signature and required supporting documentation; the form contains checkboxes for approval and denial and an authorization number when approved.

Practitioner signature and date required.
Form contains: [ ] APPROVED: Authorization # (Authorization by: ) and [ ] DENIED: checkbox.
Failure to supply required supporting documentation with the submitted form may result in denial or delayed processing.

Documentation Required

Ordering and Dosing Requirement

Prescriber must order Synagis (palivizumab) as 15 mg/kg IM every 28 days. The prescription/order must indicate the First/Next Injection Due Date and the delivery/administration location (MD office, patient home, or clinic). Dosing should be calculated at the time of injection based on the patient’s current weight.

Medication: Synagis® (palivizumab) — dispense 50 mg and/or 100 mg vials as needed to achieve prescribed dose (NDCs: 50 mg vial 60574-4114-01; 100 mg vial 60574-4113-01).
Sig: Inject 15 mg/kg IM every 28 days. Dose to be calculated at time of injection based on current weight.
Include on order: First/Next Injection Due Date and Delivery/Administration Location: ☐ MD Office ☐ Patient Home ☐ Clinic.
Quantity: QS; Refills: indicate number and duration as applicable.
If home administration is requested, include supplies (syringes/needles, epinephrine) and instructions as indicated on the form.

Background

Palivizumab (Synagis) is a monoclonal antibody given by intramuscular injection to help prevent severe respiratory syncytial virus (RSV) infection in high-risk infants and young children. The New Mexico Synagis PA/Statement of Medical Necessity/Order Form lists the standard high-risk clinical eligibility categories used to determine medical necessity (for example, prematurity, chronic lung disease of prematurity, hemodynamically significant congenital heart disease, severe immunodeficiency, severe neuromuscular disease with inability to clear secretions, airway anomalies with inability to clear secretions, and candidates for cardiac transplantation during RSV season).

Definitions Used in the Form

CLD definition as used on form — inv-12

DefinitionChronic lung disease (CLD) of prematurity requiring oxygen of FiO2 >21% for >28 days after birth

Context on formListed as part of criteria 2(a) for infants <12 months (as of Nov 15) with gestational age <32 wks 0 days

Supporting requirementOne eligibility criterion must be circled on the form and supporting documentation supplied

Prematurity — inv-13

ICD-10 codeP07.30 (Premature)

Gestational age entriesForm includes entry for gestational age with criterion 'less than or equal to 28 weeks, 6 days' and references '< 32 wks 0 days' in certain criteria

Form usageGestational age and ICD-10 code used to support eligibility when circling the appropriate criterion on the form

OpenPayer

Synagis (palivizumab) prior authorization and medical necessity/order form

Coverage Criteria for Synagis (palivizumab)

Coding, Dosing, and Interval Information

Provider Submission, Ordering, and Documentation Requirements

Background

Definitions Used in the Form

60574-4114-01	NDC - Synagis 50 mg vial
60574-4113-01	NDC - Synagis 100 mg vial