CurrentUnitedHealthcarePolicy N/A

Synagis (palivizumab) Weight Change / Vial-Size Adjustment Prior Authorization

Form and requirements for requesting a vial-size or dose increase for Synagis (palivizumab) via prior authorization, including required documentation and submission instructions for providers and pharmacies.

Policy Summary

PayerUnitedHealthcare

PolicySynagis (palivizumab) Weight Change / Vial-Size Adjustment Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the Synagis Weight Change Form with supporting documentation and fax to 1-866-940-7328 for prior authorization of weight/dose or vial-size changes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form referenced

5 yrsretain documentation

1-866-940-7328fax to

1-800-310-6826PA call center

Coverage Criteria

Dose/Vial Size Change Approval Criteria

Covered when ALL of the following are met

Weight documentation and prescriber attestation: Submission includes previous weight, current weight, new dose required, prescriber signature and date, plus weight charts or progress notes as applicable

Required for review: all copies of medical records (diagnostic evaluations and recent chart notes), most recent related labs; provider must retain documentation for five years

No immediate approvals will be issued for patients who are waiting to receive an additional vial solely because of projected weight gain. Approvals for a larger vial size require documented weight changes and must be obtained prior to administration. If a patient is expected to need an additional vial (an increase of >2.5 mg over the approved vial size as noted on the form), schedule a visit to obtain a current weight and submit the Synagis Weight Change Form with the required documentation before giving the next dose.

Provider Actions & Submission Instructions

Policy Summary

PayerUnitedHealthcare

PolicySynagis (palivizumab) Weight Change / Vial-Size Adjustment Prior Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the Synagis Weight Change Form with supporting documentation and fax to 1-866-940-7328 for prior authorization of weight/dose or vial-size changes.

SourceLink

On This Page

Prior Authorization

Prior authorization required — submit Weight Change Form

Prior authorization is required for Synagis weight or dose changes. Submit the Synagis Weight Change Form with supporting documentation and fax it to 1-866-940-7328; obtain weight and approval prior to administration when an additional vial is anticipated (no immediate approvals for “waiting” patients).

Fax completed Synagis Weight Change Form to 1-866-940-7328
Obtain and document current weight and approval before administering an additional vial

Documentation Required

Required documentation — records, labs, weight charts

Include complete supporting medical records when submitting the Weight Change Form. Required materials must be provided for review and retained for five years.

All copies of medical records (diagnostic evaluations and recent chart notes)
Most recent related laboratory results
Weight charts and/or progress notes showing previous and current weight
Prescriber signature and date on the Weight Change Form
Retain copies of all documentation for five years

Background

Synagis (palivizumab) is dosed based on patient weight; as infants gain weight, the required dose and sometimes the vial size may change. The Synagis Weight Change Form documents the previous weight, current weight, new dose required, prescriber signature and date, and requires supporting materials (weight charts/progress notes and recent related labs) to support a vial-size or dose increase request. The form and documentation must be faxed to 1-866-940-7328, and providers must retain copies of all submitted documentation for five years. If immediate administration is required, use the currently authorized vial size(s) and then submit the weight change request to apply the new vial size to subsequent doses.

Definitions

inv-08: Synagis Weight Change Form

Form nameSynagis Weight Change Form

PurposeRequest vial-size or dose increase for Synagis (palivizumab) when patient weight has changed

Required fields (examples)Date of birth; recipient full name; prescriber name, NPI, phone, fax; pharmacy name, Medicaid provider #, phone, fax; previous weight; current weight; new dose required; prescriber signature and date

Required supporting documentationAll copies of medical records (diagnostic evaluations and recent chart notes) and most recent related labs; weight charts or progress notes showing current weight; provider must retain documentation for five years

Submission methodFax the completed form to 1-866-940-7328

Help/contactsPharmacy PA Call Center: 1-800-310-6826

Site of Care Guidance

Note

Infusion center — immediate dose with current vial, then request change

For infusion center administrations that must occur immediately, use the currently authorized vial size(s) for that visit and then submit a weight change request so the new vial size, if approved, will apply to subsequent doses.

Administer immediate dose with currently authorized vial size(s) in the infusion center
Submit Weight Change Form after administration to request vial-size change for future doses