Synagis Referral Form

ADVERTISEMENT

For Internal Use Only
PA#:
Date Entered:
SYNAGIS Referral Form
Questions?
Contact the Pharmacy Dept at:
410-424-4490, option 4
FAX Completed Form & Prescription to:
or 1-888-819-1043, option 4
(410) 424-4607
Patient Information
Physician Information
Member Name:
Physician Name :
Member ID:
Office Contact:
Date of Birth:
Office Phone:
Gender:
Male
Female
Office Fax:
Parent/Guardian:
DEA #
(Prescription for Synagis MUST be attached)
Prescription Information
Synagis Vial Quantity: 100mg: _________
50 mg: _________
NICU dose administered?
No
Yes, Date(s): ____________
SIG: Inject 15mg/kg IM one time per month
Birth Weight: _______________ lbs or kg (circle one)
Desired Start Date: _______________ Refill: _______ months
Current Weight: _____________ lbs or kg (Required)
Diagnosis Information
Extreme Prematurity (< 27 wks of gestation)
Congenital Heart Disease
Prematurity (28-37 weeks of gestation)
Other ICD-9 specify: ____________________________
Chronic Respiratory Disease arising in the neonatal or
perinatal period (CLD)
Actual Gestational Age: ________________ weeks (Required)
(If applicable, attach NICU discharge summary and/or supporting progress notes)
Approval Criteria
28 wks or less gestation and less than 12 months of age at beginning of RSV season
29 wks - 31 wks 6 days gestation and less than 6 months of age at beginning of RSV season
32 wks - 34 wks 6 days gestation and less than 3 months of age at beginning of RSV season plus one of the
following risk factors:
daycare attendance
sibling(s) less than 5 yrs of age living in the home
Less than 12 months of age with diagnosis of CLD (e.g., bronchopulmonary dysplasia, BPD)
Less than 24 months of age with CLD requiring treatment with one of the following:
oxygen
diuretics
chronic bronchodilator requirement
chronic corticosteroid therapy
Tracheotomy patient less than 24 months of age with pulmonary disease
Less than 34 wks 6 days gestation and less than 12 months of age at beginning of RSV season plus one of the
following:
congenital airway abnormality
neuromuscular condition that compromises handling of secretions
Less than 24 months of age with cyanotic/acyanotic CHD plus one of the following:
receiving medication to control CHF
moderate to severe pulmonary hypertension
Less than 12 months of age with severe immunodeficiency
I certify that the clinical information provided on this form is complete and accurate.
Provider Signature: _________________________________________________ Today’s Date: _______________
For Internal Use Only
Approved:
Duration of Approval:
*Denied:
Authorized By:
Incomplete/Other:
Name:
*Send all appeals to Priority Partners. DO NOT send appeals to the pharmacy vendor.
Revised August 2009

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go