Prior Authorization Request Form (Synagis) - Utah Department Of Health printable pdf download

UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM

SYNAGIS (palivizumab)

Patient Name:______________________________________Medicaid ID #:____________________________

Prescriber Name:___________________________________Prescriber NPI#:___________________________

Contact Name:_________________Prescriber Phone#:________________Prescriber Fax#:________________

Pharmacy:_____________________Pharmacy Phone#:________________Pharmacy Fax #:_______________

Child’s gestational age____________________Birth date___________________Current Wt.______________

All information must be legible, complete and correct or form will be returned.

FAX DOCUMENTATION FROM PROGRESS NOTES

AND A LETTER OF MEDICAL NECESSITY TO 855-828-4992

All of the Following are Eligible for a Maximum of Five (5) Doses

(the last dose must be given

on or before April 30, regardless of when treatment began)



Premature infants (born < 29 weeks, 0 days gestation) during their first year of life



Premature infants (born < 32 weeks, 0 days) who received > 21% oxygen for at least 28 days immediately

after birth, during their first RSV season



Infants < 12 months of age if they have been diagnosed with

o congenital abnormalities of the airway

o neuromuscular disease that compromise(s) handling of respiratory secretions

o acyanotic heart disease AND currently being treated for CHF AND will undergo a cardiac procedure

o moderate to severe pulmonary hypertension



Children < 24 months of age with chronic lung disease of prematurity and who required at least 28 days of

supplemental oxygen immediately after birth and who continue to require medical intervention

(supplemental oxygen, chronic corticosteroid, or diuretic therapy).



Children younger than 24 months who will be profoundly immunocompromised during the RSV season.

PLEASE NOTE:



ALL SYNAGIS (DRUG) MUST BE BILLED VIA PHARMACY POINT OF SALE. UTAH

MEDICAID CANNOT REIMBURSE PHYSICIANS’ OFFICES FOR THE DRUG. NO

EXCEPTIONS.



The Utah Medicaid Synagis season is December 1

through April 30

. A maximum of five monthly Synagis

doses may be given during this five month period.



Synagis is not available to any child with active RSV.



No approval will be given to a child of 24 months or older.



When an infant begins a Synagis series late in the season, they may receive monthly doses until April 30

, as

appropriate, according to the criteria above. A child who begins the series and then turns two may receive

monthly doses until April 30

, as appropriate, according to the criteria above.



The DUR Board considered recommendations from the American Academy of Pediatrics, the manufacturer,

and the FDA approved indications in developing these criteria. Therefore, prescribers seeking approval

outside the above criteria must provide literature that demonstrates support for the requested use.

Consideration of the request will not proceed without it. NO EXCEPTIONS.

Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of

Hospitalization for Respiratory Syncytial Virus Infection. Pediatrics 2014; 134:415. Published online July 28, 2014,

12/01/2014

https://medicaid.utah.gov/pharmacy/

Prior Authorization Request Form (Synagis) - Utah Department Of Health

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