CurrentColorado Rocky Mountain Health PlansPolicy N/A

Synagis (palivizumab) — Weight Change Authorization Form

This document is a payer form governing requests to change the authorized Synagis (palivizumab) dose based on patient weight for Colorado Rocky Mountain Health Plans members; it affects prescribers and pharmacies submitting prior authorization or weight-change requests.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySynagis (palivizumab) weight change authorization form

Policy CodePolicy N/A

Change TypeAdministrative — form/criteria clarification

Effective DateN/A

Next Review DateN/A

Key ActionComplete the weight-change form in full and fax it with required medical records and labs to 1-866-940-7328 to request approval for a new vial size.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 mgdose rounding threshold

5 yearsretain documentation

1-866-940-7328fax to submit

1-800-310-6826PA call center

Coverage criteria for weight-change authorization

Weight change authorization criteria

Covered adjustment when ALL of the following are met

Weight change request requirements: Form completed in full; include previous and current weight, new dose required, prescriber signature, and required medical records/labs/chart notes; fax to provided number

Incomplete forms may be returned; provider must retain documentation for five years; submit to fax 1-866-940-7328

There are no immediate approvals for patients who are only "waiting" (i.e., not yet presenting for administration). Requests to change the authorized Synagis dose based on weight must be submitted using the completed form; if a patient is expected to need a larger vial due to future weight gain, schedule a visit to obtain the weight and submit the weight-change request prior to the administration date. For cases where immediate administration is required, use the currently authorized vial size(s) for that dose and submit a weight change request to apply to subsequent doses.

Dose rounding and coding guidance

Dose rounding threshold (inv-03)

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySynagis (palivizumab) weight change authorization form

Policy CodePolicy N/A

Change TypeAdministrative — form/criteria clarification

Effective DateN/A

Next Review DateN/A

Key ActionComplete the weight-change form in full and fax it with required medical records and labs to 1-866-940-7328 to request approval for a new vial size.

SourceLink

On This Page

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What providers must do to request a weight-based dose change

Prior Authorization

Prior Authorization Required

Weight-based dose change requests for Synagis must be submitted on the Synagis Weight Change Form and completed in full. An incomplete form may be returned or denied; ensure all fields (recipient name, Medicaid ID, DOB, prescriber and pharmacy information, previous and current weights, and new dose required) are completed.

Fax form to 1-866-940-7328
Pharmacy PA Call Center: 1-800-310-6826

Documentation Required

Required documentation

Include supporting clinical documentation with the weight change form: weight charts or progress notes documenting current weight, relevant diagnostic evaluations, recent chart notes, and the most recent related labs. Providers must retain copies of all submitted documentation for five years.

Note

Provider actions — dosing and scheduling guidance

If the dose increase requested is less than 5 mg over the approved vial size, round down to the nearest vial size. If the dose is ≥ 5 mg over the approved vial size, the new vial size may be approved. For patients expected to gain weight such that an additional vial will be needed, schedule a visit to obtain weight and request approval prior to the Synagis administration date. There are no immediate approvals for patients who are 'waiting' for dose changes.

Denial Risk

Incomplete submission risk

For situations requiring immediate administration, use the currently authorized vial size(s) at the time of dosing and then submit the weight change request; any approved change will apply only to subsequent doses. Remember: incomplete submissions (missing weights, supporting notes, signatures, or required lab copies) may be returned or result in denial.

Background and definitions

Synagis (palivizumab) dosing is weight-based and may require changing the authorized vial size when a patients weight increases. The form standardizes requests for dose increases by requiring previous and current weight, the new dose required, prescriber signature, and supporting documentation. The form also codifies the dose-rounding rule: if the dose needed is less than 5 mg over the approved vial size, round down to the nearest vial size; if the dose needed is 3333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333≥ 5 mg over the approved vial size, a new vial size will be approved. The form also requires submission of copies of medical records and the most recent related labs and notes for review, with retention of documentation for five years.

Dose rounding threshold (definitions) (inv-09)

Primary ruleIf the dose needed is less than 5 mg over the approved vial size, round down to the nearest vial size

New vial approval ruleIf the dose needed is >= 5 mg over the approved vial size, the new vial size will be approved

Practical noteFor patients expected to gain enough weight for an additional vial, schedule a visit to obtain weight and receive approval prior to administration

Immediate admin exceptionWhen immediate administration is required, use currently authorized vial size(s) and submit a weight change request for future doses

OpenPayer

Synagis (palivizumab) — Weight Change Authorization Form

Coverage criteria for weight-change authorization

Dose rounding and coding guidance

What providers must do to request a weight-based dose change

Background and definitions

Administration site and immediate dosing guidance