CurrentHarvard Pilgrim Health CarePolicy N/A

Synagis (palivizumab) prior authorization form / coverage criteria

Standard Massachusetts prior authorization form used by Harvard Pilgrim Health Care for requests for Synagis (palivizumab), governing providers submitting authorization requests for eligible pediatric patients. Affects prescribers, servicing providers, and Pharmacy Utilization Management.

Policy Summary

PayerHarvard Pilgrim Health Care

PolicySynagis (palivizumab) prior authorization form / coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit prior authorization to Harvard Pilgrim Pharmacy Utilization Management with required patient details, ICD code, gestational age, prior doses and billing information (phone/fax provided).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2014 AAPClinical guidance referenced for eligibility

1form for Synagis prior authorization

1.800.708.4414Health Plan phone for Pharmacy UM

1.617.673.0988Health Plan fax

ICD code(s)Diagnosis required on form

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

Initial eligibility criteria

Covered when documentation shows one of the listed high‑risk clinical conditions consistent with 2014 AAP guidance and required patient attributes are provided.

High‑risk condition present

CLD specific: CLD of prematurity defined as gestational age ≤31 weeks, 6 days AND requirement for 21% oxygen for at least the first 28 days after birth. Age categories on the form: <12 months of age with CLD; or 12–24 months with CLD who continue to require medical support during the 6‑month period before the second RSV season. Form requests supplemental oxygen dates, diuretic therapy dates, and chronic corticosteroid dates.gestational age ≤31w6d; oxygen ≥ first 28 days
Checkboxes provided for age categories and for documentation of oxygen, diuretics, and corticosteroids.

Prematurity criterion: gestational age ≤28 weeks, 6 days AND age <12 months at start of RSV season (provider must check the prematurity box).GA ≤28w6d AND age <12 months at season start

Checkbox present on form for prematurity eligibility.

This form is the Massachusetts standard prior authorization request for Synagis® (palivizumab). Note that some plans might not accept this form for Medicare or Medicaid requests; providers should confirm plan-specific submission requirements before using this form for members covered by Medicare or Medicaid.

Initial Therapy

Initial therapy

Initial therapy is permitted when the patient meets at least one high‑risk condition listed on the form and the provider supplies the requested supporting clinical details.

Initial eligibility: Patient meets at least one high‑risk condition as listed on the form (CLD, chronic respiratory disease of perinatal origin, congenital heart disease, airway/neuromuscular conditions, prematurity, cystic fibrosis, Down syndrome, or immunocompromised), and the provider has completed the condition‑specific fields (gestational age, oxygen/medication dates, surgery dates, and attached clinical notes as requested).N/A

Form mirrors 2014 AAP high‑risk condition checkboxes and requests specific supporting dates/attachments where applicable.

Reauthorization / Continuation Criteria

Reauthorization/Continuation

Reauthorization or ongoing therapy requires documentation that the patient is currently on therapy and a record of prior doses received.

Reauthorization documentation: If request is for reauthorization, the provider must indicate 'Yes' for reauthorization and provide date therapy was started, date of last dose received, total number of doses previously received, and the number of doses being requested; include servicing provider and billing details (start/end dates, servicing provider name/NPI, CPT/J‑code, units).N/A

Form contains explicit fields for reauthorization status, date started, date of last dose, number of doses received, and number of doses requested; professionally administered medication section collects servicing/billing information.

Coding and Definitions

Administration and drug billing codesmixed

CPT	CPT Code (field present on form)
J	J Code (field present on form) for palivizumab

Example ICD-10 codes referenced in clinical conditionsICD-10

P27.0	Wilson-Mikity Syndrome (listed)
P27.1	Bronchopulmonary Dysplasia originating in the perinatal period (listed)
P27.8	Other chronic respiratory disease originating in the perinatal period (listed)

inv-05: Gestational age threshold for CLD definition

Gestational age threshold≤31 weeks, 6 days

ContextPart of CLD of prematurity definition per 2014 AAP guidance

Used on form fieldCheckbox and gestational age entry requested for CLD assessment

inv-06: Oxygen requirement duration for CLD

Oxygen requirement durationRequirement for 21% oxygen for at least the first 28 days after birth

AssociationRequired element of CLD of prematurity definition per 2014 AAP guidance

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Submission Requirements

Prior Authorization Required: Prior authorization is required for coverage. Submit requests using the plan's online portal when available or via Pharmacy Utilization Management phone or secure fax. Include the completed Massachusetts Synagis® prior authorization form or the plan-specific prior authorization form. Some plans may not accept this form for Medicare or Medicaid requests.

Submit via plan online portal when available: https://point32health.promptpa.com
Pharmacy UM phone/fax — use health plan contact details on member card or plan website
Attach completed prior authorization form and any supporting clinical documentation

Documentation Required

Expedited Review Attestation

Attestation for Expedited Review: If requesting expedited/urgent review, the prescriber must check the expedited review box on the form and attest that the request meets the definition and criteria for expedited review and is urgent.

Site of Care

Note

Provide servicing provider/facility information (no site restriction)

The form collects servicing provider and facility information for professionally administered medications (infusion center, office, hospital outpatient, or home); there is no explicit site-of-care restriction stated on the form.

Servicing Prescriber/Facility Name (option to indicate same as prescribing clinician), Servicing Provider/Facility Address, Servicing Provider NPI/Tax ID #
Billing Provider name and Billing Provider NPI #

Quantity Limits

inv-16: palivizumab (Synagis) — provider-entered number of doses requested

Number of doses requestedProvider-entered number of doses requested (field present on form)

Reauthorization fieldsIf reauthorization, form requests date started, date of last dose, and number of doses received

Administration billing detailsForm includes CPT/J-code, # of units, start/end dates and servicing provider/billing provider information

Definitions

inv-13: Chronic Lung Disease (CLD) of prematurity definition

CLD definition—gestational age≤31 weeks, 6 days

CLD definition—oxygenRequirement for 21% oxygen for at least the first 28 days after birth

Source guidancePer 2014 AAP Committee on Infectious Disease and Bronchiolitis Guidelines (as cited on form)

Background

The clinical eligibility checkboxes on the form reference the 2014 AAP Committee on Infectious Disease and Bronchiolitis Guidelines. The form uses those guidelines to define high-risk conditions (for example, chronic lung disease of prematurity, congenital heart disease, prematurity, airway/neuromuscular disorders, cystic fibrosis, Down syndrome, and immunocompromised states) and requests supporting clinical details consistent with that guidance.