Synagis Prior Authorization Form - Department Of Social Services, South Dakota
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1DEPARTMENT OF SOCIAL SERVICES
DIVISION OF MEDICAL SERVICES
700 GOVERNORS DRIVE
PIERRE, SD 57501-2291
PHONE: 605-773-3495
FAX: 605-773-5246
WEB:
dss.sd.gov
SYNAGIS/RESPIGAM PRIOR AUTHORIZATION
Patient Name:____________________________ DOB: __________________ Medicaid #: ___________________________
Provider Name: ___________________________ Provider # ________________ Location: ___________________________
Contact Person: ___________________________ Phone#:_____________________ Fax#: ___________________________
Synagis and Respigam are covered by the South Dakota Medicaid Program when a child meets one of the following criteria
and it has been recommended by a Neonatologist, Pediatric Pulmonologist, or Pediatric Cardiologist:
____A
Children under 6 months of age at the onset of the RSV season who were 32 weeks or less gestational age at
birth.
____B
Children under 3 months of age at the onset of the RSV season or who are born during the RSV season (11/01 -–
03/31) who were between 32 and 35 weeks gestational age at birth with one of these 2 risk factors: Day care
attendance or A sibling in the household less than 5 years of age.
____C
Children under 2 years of age at the onset of the RSV season with evidence of ongoing lung disease such as
bronchopulmonary dysplasia or cystic fibrosis requiring treatment with oral bronchodilators, supplemental oxygen,
diuretics, or nebulized or inhaled medications to stabilize the disease in the last 6 months.
____D
Children under 2 years of age at the onset of the RSV season with evidence of hemodynamically significant
cyanotic or acynatotic congenital heart disease and one of the following: Receiving medication to control
congestive heart failure; Moderate to severe pulmonary hypertension, or Undergoing surgical procedures that
use cardiopulmonary bypass.
____E
Children under two years of age at the onset of the RSV season with immunodeficiencies that may make them
more susceptible to severe lower respiratory tract disease related to RSV.
____F
Any child under 2 years of age at the onset of the RSV season felt to be at high risk for significant lower
respiratory tract illness related to RSV.
Diagnosis: ____________________________________________________________________________________________
Hospitalizations/Treatment/Medications Used in the last 6 months:____________________________________________
Gestational age at birth: _______________________
Neonatologist, Pediatric Pulmonologist, or Pediatric Cardiologist: (REQUIRED)
Printed Name: ________________________________Signature:_______________________________________________
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