Fa-65 Synagis Prior Authorization Form

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Prior Authorization Request

Hewlett Packard Enterprise – OptumRx

Synagis

Prior Authorization

Submit fax request to: 855-455-3303

Purpose: For a prescribing physician to request Synagis

for the Nevada Respiratory Syncytial Virus (RSV) season November

1, 2014, through April 1, 2015. Synagis

authorization will not be issued for therapy dates in the 2014 season after April 1, 2015.

Questions: If you have questions, call the Clinical Pharmacy Services Call Center for Nevada Medicaid at 855-455-3311.

DATE OF REQUEST:

RECIPIENT INFORMATION

Last name, First name, Middle initial:

Date of birth:

Recipient ID:

Gender:

Male

Female

Phone:

Gestational age: ______ Weeks ______ Days *Both weeks and days are required.

Current weight:______________

Date on which current weight was recorded:

PROVIDER INFORMATION

(This request must be submitted by the prescribing physician.)

Name:

NPI:

Specialty:

Phone:

Fax (required):

Person to contact regarding this request:

COVERAGE CRITERIA

Please check the applicable boxes to indicate each item as true for the recipient:

Child is <12 months of age at the onset of RSV season on November 1 (born after 11/1/13).

Child is <24 months of age at the onset of RSV season on November 1 (born after 11/1/12).

Child has a diagnosis of chronic lung disease of prematurity (formerly called bronchopulmonary dysplasia).

Child has required medical treatment for chronic lung disease of prematurity in the preceding six months (only

required if child is ≥ 12 months of age). Please check all that apply and document administration dates:

Oxygen

Most recent date administered: __________________________

Corticosteroids

Most recent date administered: __________________________

Bronchodilators

Most recent date administered: __________________________

Diuretics

Most recent date administered: __________________________

Child has hemodynamically significant cyanotic or acyanotic congenital heart disease (CHD)

Please check all that apply and document medications received or date of surgeries:

Congestive heart failure/cardiomyopathy; Medications: _____________________________________

Moderate to severe pulmonary hypertension; Medications:____________________________________

Cyanotic heart disease; Medications: ___________________________________________________

Cardiopulmonary bypass surgery; Date: _________________________________________________

Other diagnosis; Document:__________________________Medications:_________ ______________

The child has congenital abnormalities of the airways. Document:_________________________________

The child has a neuromuscular disease that impairs the ability to clear secretions from the upper airway.

Document diagnosis:__________________________________________________________________

Child has had or will have a cardiac transplant; Date of transplant:_________________________________

Child is severely immunocompromised during the RSV season; Document:______________________________

Child has cystic fibrosis: (please check all that apply):

Child has clinical evidence of chronic lung disease.

Child has clinical evidence of nutritional compromise.

For children with cystic fibrosis ≥ 12 months of age:

Weight-for-length less than 10th percentile; Length:_______________

Child has had previous hospitalization for pulmonary exacerbation in the first year of life.

Child has abnormalities on chest radiography or chest computed tomography that persists when stable.

PROVIDER CERTIFICATION –

Prescriber’s signature and date are required.

I hereby certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by Nevada

Medicaid.

Prescriber’s Signature:

Date:

This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions,

coordination of benefits and other terms and conditions set forth by the benefit program. The information on this form and on accompanying attachments is privileged

and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the employee or agent

responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited.

If this communication is received in error, the reader shall notify sender immediately and destroy all information received.

FA-65

10/20/2014 pv09/11/2013

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