CurrentHighmark Blueshield NenyPolicy N/A

Palivizumab (Synagis) prior authorization for infants

This form governs prior authorization requests for Synagis (palivizumab, CPT 90378) for infants and young children under the Highmark BlueShield NENY medical benefit; it is used by ordering providers to request doses during the local RSV season.

Policy Summary

PayerHighmark Blueshield Neny

PolicyPalivizumab (Synagis) prior authorization for infants

Policy CodePolicy N/A

Change TypeNo material changes in this revision

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed Synagis authorization request form with clinical criteria and attachments; fax to 1-833-619-5745.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Max 5doses allowed within RSV season

90378billing code

1-833-619-5745fax

Coverage Criteria for Palivizumab (Synagis)

Potential qualifying clinical conditions (form-based)

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Age: Current age ≤ 12 months OR current age >12 months to <24 months (checkboxes collected on form)age buckets

Form collects age category via two checkboxes

Prematurity and chronic lung disease: Infant with preterm birth <29w0d; OR infant with preterm birth <32w0d with chronic lung disease (CLD). The form requests maximum percent oxygen required after birth and number of days after birth the oxygen was required.gestational age / oxygen requirement

Provide maximum % oxygen required and duration as requested on form

Hemodynamically significant congenital heart disease: Infant with hemodynamically significant congenital heart disease. Form asks whether infant is receiving medication to control congestive heart failure and will require cardiac surgical procedures, and asks about moderate to severe pulmonary hypertension and cyanotic heart disease (YES/NO checkboxes).clinical cardiac features

Document CHF medications, planned cardiac surgery, pulmonary hypertension, cyanotic disease responses on form

Airway / Neuromuscular / Cystic Fibrosis: Infant born with congenital airway abnormalities; OR infant born with a neuromuscular condition that compromises handling of respiratory secretions; OR infant with Cystic Fibrosis with evidence of chronic lung disease (CLD) or nutritional compromise.diagnostic categories

Form includes separate checkboxes for each condition

Profound immunocompromise or transplant: Infant is profoundly immunocompromised during the RSV season OR infant is undergoing a cardiac transplant (checkboxes present on form).immunocompromise / transplant status

Select relevant checkbox and attach supporting documentation

Severe lung disease indicators: Infant has symptoms of severe lung disease (e.g., prior hospitalization for pulmonary exacerbation in the first year of life or abnormal chest imaging that persists when stable) and/or has weight or length <10th percentile (YES/NO checkboxes captured on form).clinical severity / growth

Form asks YES/NO for severe lung disease and for weight/length <10th percentile

Chronic lung disease medical support: Infant with history of chronic lung disease of prematurity that continues to require medical support such as chronic corticosteroids, diuretic therapy, supplemental oxygen, or other specified therapies (checkboxes provided).ongoing therapies

Indicate which therapies are required using the listed YES/NO checkboxes and attach documentation

Other clinical information: Other relevant conditions or clinical details may be entered in the 'Other' free‑text fields on the form; attach all pertinent clinical information as indicated.documentation

Form includes 'Other' fields and requests attachment of supporting documentation

Coding and Quantity Limits

Covered CPT CodesCPTCovered

90378

Synagis (palivizumab) per CPT listing

Maximum doses per RSV season

Maximum doses per RSV seasonMaximum of 5 doses within the local RSV season

Dose documentationProviders must submit the completed Synagis authorization form with clinical criteria and dosage requests

Submission methodFax the completed form to Highmark at 1-833-619-5745

Age eligibility buckets collected on form

Age bucket 1Current age ≤ 12 months

Age bucket 2Current age >12 months to <24 months

Form instructionCheck all that apply — age category checkboxes collected on the authorization form

Provider Actions, Submission & Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required — Providers must submit the completed Synagis Authorization Request Form with all clinical criteria and supporting documentation for Synagis (CPT 90378 / HCPCS J-code billed per dose). Fax the completed form to Highmark at 1-833-619-5745. Verify member eligibility and benefits prior to submission.

Affected codes: Synagis (CPT 90378) — prior auth required
Fax: 1-833-619-5745
Include dispensing selection: Specialty Pharmacy or Buy & Bill

Step Therapy

Step therapy — None specified on the Synagis authorization form. There is no step-therapy requirement documented; providers should not delay requests pending step edits but must meet clinical criteria and submit required documentation.

No prior medication trials or step sequence required per form
Process requests based on submitted clinical criteria and eligibility verification

Documentation Required

Required Submission Documents

Required submission documents — Submit the completed authorization request form including member demographics and UMI, physician information (name, NPI), dispensing information (specialty pharmacy or buy & bill), start date, number of doses already received this RSV season and number of doses requested (maximum of 5 per local RSV season), gestational age, birth/current weight, and all supporting clinical information that documents applicable indications checked on the form.

Member name, DOB, UMI and payer (Medicare/Commercial)
Physician name and NPI
Dispensing choice and start date
Number of doses received and number requested (max 5)
Clinical fields: gestational age, % oxygen required after birth and days, CLD status, CHD details, pulmonary hypertension, cyanotic heart disease, airway or neuromuscular abnormalities, cystic fibrosis details, immunocompromised status, transplant status, weight/length percentile, ongoing medical support (corticosteroids, diuretics, supplemental oxygen)
Attach all pertinent clinical records and prescription/referral to dispensing pharmacy if applicable

Denial Risk

Missing Documentation / Eligibility Verification

Missing documentation/eligibility verification — Failure to attach required clinical information or to verify member eligibility and benefits may prevent processing or lead to denial. Ensure all pertinent clinical records are attached and eligibility is confirmed before faxing the form.

If 'Attached' = NO, the request may be delayed or denied
Confirm member eligibility/benefits with the health plan prior to submission
Incomplete clinical fields (eg, missing gestational age, oxygen details, or number of prior doses) may cause return-to-provider

Background

Palivizumab (Synagis) is requested via this prior authorization form to prevent severe respiratory syncytial virus (RSV) in high‑risk infants. The form collects risk factors commonly associated with increased RSV severity — including prematurity, chronic lung disease, hemodynamically significant congenital heart disease, congenital airway abnormalities, neuromuscular conditions that impair secretion clearance, cystic fibrosis with complications, profound immunocompromise, and post‑transplant status — and asks for age, oxygen exposure history, symptom/hospitalization history, and growth data to support the request.

OpenPayer

Palivizumab (Synagis) prior authorization for infants

Coverage Criteria for Palivizumab (Synagis)

Coding and Quantity Limits

Provider Actions, Submission & Authorization Requirements

Definitions

Background