Synagis Prior Authorization Request Form printable pdf download

Texas Medicaid Vendor Drug Program

Respiratory Syncytial Virus (RSV) Season

2015-2016 | Synagis® Prior Authorization Request Form

About

Synagis

is a prescription medication that is used to help prevent serious lung disease caused by respiratory

syncytial virus (RSV) in infants and children at high risk.

The information and form contained in this document should be used to obtain prior authorization for clients who

meet the specified criteria. The start of RSV season varies based on a client’s county of residence. A county table is

available on the Navitus Website at

https://

or on the

Texas Vendor Drug Program Website at

Initial Dosage

The provider or provider's agent should send a completed Medicaid Synagis

Prior Authorization Request Form

which includes (1) preferred pharmacy, (2) patient demographics, (3) patient diagnosis, and (4) Synagis

prescription (bottom of the form), in addition to any supporting clinical information to one of the preferred

pharmacies listed at the top of the form.

The pharmacy faxes the completed form to the

NAVITUS Prior Authorization Department

at 1-855-668-8553.

If the information submitted demonstrates medical necessity, the request is approved, and both the pharmacy and

provider are notified via approval letters. The dispensing pharmacy fills the prescription and ships an individual

dose of Synagis

, in the name of the Medicaid patient, directly to the provider. An initiation packet that contains

information about Synagis

is to be mailed by the pharmacy to the patient’s family.

The physician or provider under the direct supervision of the physician administers the Synagis

. The administering

provider may only bill for an injection administration fee and any medically necessary office-based evaluation and

management services provided at the time of injection. The pharmacy is reimbursed for the drug and dispensing

fees.

If the information submitted does not demonstrate medical necessity then the request is denied and both the

pharmacy and provider are notified of the denial via denial letters. Based on the 2014 American Academy of

Pediatrics guidance, prophylactic Synagis

injections should not continue if a patient is hospitalized for RSV,

therefore patients who are hospitalized for RSV while being treated with Synagis

may not be approved for

subsequent doses.

Subsequent Dosage

Patients are allowed up to 5 monthly doses of Synagis

. Depending on the date of the initial dose, a patient may not

receive all 5 monthly injections before the end of season. The pharmacy must contact the prescriber to:



Verify that the patient has not experienced a breakthrough RSV hospitalization



Obtain patient’s updated weight



Verify that the patient was administered all previously dispensed Synagis

doses



Pharmacies should maintain a log of the information obtained from the injecting provider

Contact

Fax the completed prior authorization form to NAVITUS at 1-855-668-8553.

Providers with questions should call the NAVITUS Texas Provider Hotline at 1-877-908-6023.

Dispensing Pharmacy FAX completed form to NAVITUS for approval: 1.855.668.8553

PH-0915-099

Effective Date: 09/2015

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Synagis Prior Authorization Request Form

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