Shp_20151159 - Prior Authorization Form Page 2

Prior Authorization Form for the 2015-2016 Synagis® Season

Specialty Pharmacy Name:___________________________

Specialty Pharmacy Phone:___________________________

Today’s Date:________ Date Medication Required:________

Phone: 1-800-218-7453 ext. 22080

|

Fax: 1-866-683-5631

7. Will patient be profoundly immunocompromised during this RSV season (solid organ or hematopoietic stem cell transplant,

chemotherapy, or other condition that leaves the infant profoundly immunocompromised)?

Yes

No

❑

❑

If yes, please explain:

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

8. Does the patient have a diagnosis of cystic fibrosis with severe lung disease or cystic fibrosis with weight and length less

than the 10

percentile?

Yes

No

th

❑

❑

If yes, please explain:

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

9. For any diagnosis questions with a response of yes from above please include the applicable ICD-10

code(s):______________________________________________________________________________________________

Please include any additional clinical information you wish to have considered for possible approval of Synagis that are not

discussed above: ______________________________________________________________________________________

MEDICATION

STRENGTH

DIRECTIONS

QUANTITY

REFILLS

**As a reminder, a prescription should be sent to the specialty pharmacy directly.

Physician’s Signature: _________________________________________ Date____/_____/____

IMPORTANT NOTICE:

This facsimile transmission is intended to be delivered only to the name addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure under applicable

law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the

transmitted material. In no event should such material be read or retained by anyone other than the name addressee, except by express authority of sender to the name addressee.

The following groups of infants are NOT AT INCREASED risk of RSV and generally should not receive immunoprophylaxis:

•

Hemodynamically insignificant heart disease.

Secundum atrial septal defect

•

Small ventriculoseptal defect

•

Pulmonic stenosis

•

Uncomplicated aortic stenosis

•

Mild coarctation of the aorta

•

Patent ductus arteriosus

Congenital heart disease adequately

corrected by surgery which does not continue

to require medication for congestive heart

failure.

Mild cardiomyopathy that does not

require medical therapy for the condition.

Children in the second year of life on the basis of a history of prematurity alone.

Note: Tobacco smoke exposure is not an indication for Synagis administration. Tobacco-dependent parents should be offered tobacco

dependence treatment or referral for tobacco dependence treatment. 1-877-YES-QUIT (1-877-937-7848, ) is the quit line operated

in Texas.

SHP_20151159