Prior Authorization Of Benefits (Pab) Form
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2For your convenience and prior auth coordination, please fax to Maxor Specialty at (866) 217-8034
CONTAINS CONFIDENTIAL PATIENT INFORMATION
Synagis
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 357-9577
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Prescribing Physician: ____________________________
Patient Name: __________________________________
Physician Address:
_____________________________
Patient ID #:
__________________________________
Physician Phone #:
_____________________________
Patient DOB: __________________________________
Physician Fax #:
_____________________________
Date of Rx:
__________________________________
Physician Specialty:
____________________________
Patient Phone #: _______________________________
Physician DEA:
____________________________
Patient Email Address: ___________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
Specify: _________________
________________
Synagis
______________________
7. DIAGNOSIS: ______________________________________________________________________________
CHECK ALL BOXES THAT APPLY
8. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
Please indicate the patients age at the start of the Respiratory Syncytial Virus (RSV) season: ______________________
□
□
Yes
No Was the patient born prematurely?
If yes, please indicate the gestational age of the infant: ___________________________________
□
□
Yes
No
Patient has chronic lung disease (CLD) [formerly designated Bronchopulmonary Dysplasi (BPD)]
□
□
Yes
No
Patient has required medical treatment within six months before the start of RSV
season with oxygen, chronic steroids, bronchodilators or diuretics
□
□
Yes
No
Patient has hemodynamically significant (for example, but not limited to, receiving
medication for congestive heart failure or moderate to severe pulmonary hypertension) cyanotic or
acyanotic congenital heart disease (CHD)
□
□
Yes
No
Patient is under 2 years of age and has significant congenital abnormalities of the airway (for example,
tracheal ring) or a neuromuscular condition, either of which compromises the handling of respiratory
secretions
□
□
Yes
No
Are there currently any risk factors present? If yes, please select any that apply:
□
Patient lives with older siblings or other children who are less than 5 years of age (not including twins
or triplets of the patient)
□
Patient attends group child care
□
Other: ________________________________________
□
□
Yes
No
Patient is in an approved course of treatment, has undergone cardiopulmonary bypass for surgical
procedures, and has documented reduction in serum levels post-bypass
If yes, please indicate the date of the procedure: _______________________________________
PAGE 1 OF 2, CONTINUED ON PAGE 2
Blue Cross and Blues Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue
Shield Association. The relationship between BCBSTX and Express Scripts is that of an independent contractor. Express Scripts is a separate company and is the pharmacy
benefits manager for the BCBSTX STAR and CHIP business.
2012 TXWPA14 10/09/2012
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