Drug Health Services Review Form

SYNAGIS or RESPIGAM

Mail this form to:

Or fax to:

Drug Prior Authorization

In Richmond: 804-354-2120

Prescription Drug Program

Unit Mail Drop VA44E

Outside 800-896-5125

PO Box 85040

Drug Health Services Review Form

Medical Emergency Only:

Richmond, VA 23261-5040

(800) 553-1120

ALL APPROVALS THROUGH THE USE OF THIS FORM ARE

SUBJECT TO THE PARTICIPANT’S POLICY.

Patient’s Name

Policyholder ID#

Patient’s Date of Birth:

Patient’s address:

Policyholder Name:

City, State & Zip:

Drug acquisition (Please check one):

Purchase through outpatient drug benefit (if applicable).

Procurement and reimbursement through physician's office.

Please respond to the following questions. Incomplete information may result in delay of processing your request.

Current weight:_______________lb or kg

Patient's gestational age at birth _________________Weeks

MEDICAL CRITERIA (PLEASE CHECK ALL THAT APPLY AND PROVIDE DETAILS AS REQUESTED)

Diagnosis of Chronic Lung Disease (Bronchopulmonary Dysplasia)? (Note that asthma or reactive airway disease does not

meet the definition of Chronic Lung Disease for purposes of medical coverage.)

List treatments for CLD within the past 6 months, e.g.; CORTICOSTEROIDS, BRONCHODIALATORS, DIURETICS,

OXYGEN:

__________________________________________________________________________________________________

Diagnosis of other severe acute respiratory episode in the past 6 months?

List ICD-9-CM Codes:______________________________________________________________________________

List treatments:____________________________________________________________________________________

________________________________________________________________________________________________

Diagnosis of hemodynamically unstable congenital heart disease?

List treatments for CHD: ___________________________________________________________________________

Other significant risk factors (check all that apply)

Child care attendance outside the home

Exposure to tobacco smoke at home

Siblings: List ages_________________________________

Congenital abnormalities of airway

Diagnosis of Neurologic/Neuromuscular Disease, List ICD-9-CM codes:__________________________________________

List the date(s) of prior Synagis injections:______________________________________________________________________

I certify that this information is correct. I understand that intentional misrepresentation of information herein may constitute fraud and

may be subject to action.

Physician’s Signature:

Date:

Fax #:_______________ Phone #________________

Physician’s Name: (Please Print):

Address: Please Print)

City/State/Zip:

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc.• Anthem Blue Cross and Blue Shield and its affiliated HMOs, HealthKeepers, Inc., Peninsula

Health Care, Inc., and Priority Health Care, Inc., are independent licensees of the Blue Cross and Blue Shield Association. •  Registered marks Blue Cross and Blue Shield Association.

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