Prior Authorization Form Synagis

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Today’s date _____________________
Prior Authorization Form
Date medication needed ___________
®
Synagis
(palivizumab)
ONLY COMPLETED REQUESTS WILL BE REVIEWED
Patient information (please print)
Patient name ______________________________________ Subscriber name ____________________________________
Address __________________________________________ City, state, ZIP ______________________________________
Telephone # ________________________ Member ID # _____________________ Date of birth ______________________
Gestational age ___________ Chronological age ___________ Current weight __________ Date recorded ______________
Does the patient have any allergies?
Yes
No
Previous injections? (including doses given in NICU)
Yes: # of doses ______ Dates given __________________________
No: Expected date of 1st or next injection ______________________
Physician information (please print)
Prescribing physician ____________________________________________ Prescriber NPI __________________________
Office address _______________________________________ City, state, ZIP ____________________________________
Office contact __________________________________ Telephone # ____________________ Fax # __________________
Diagnosis and patient history (check all that apply)
Chronic pulmonary disease (CLD/BPD) (specify ICD-9 code and complete a – h below) ________________________
Attach supporting documentation, including pulmonary consults.
a. Does patient have bronchopulmonary dysplasia (BPD)?
Yes
No
b. Does patient have interstitial pulmonary fibrosis of prematurity?
Yes
No
c. Does patient have Wilson-Mikity syndrome?
Yes
No
d. Does patient have chronic obstructive asthma?
Yes
No
Yes
No
e. Does patient have chronic bronchitis?
Yes
No
f. Does patient have bronchiolitis?
g. Other __________________________________________________________________
Yes
No
h. Is patient receiving medical treatment? (check all that apply below and provide dates)
Yes
No
Oxygen (dates _________________)
Corticosteroids (dates _________________)
Diuretics (dates ________________)
Bronchodilator (dates _________________)
Congenital heart disease (CHD) — 747.0 to 745.4 (specify ICD-9 code; complete a – c below) ___________________
Attach supporting documentation, including latest cardiology consults, echocardiograms/catheterization records.
a. Diagnosis of hemodynamically significant congenital heart disease?
Yes
No
b. Diagnosis of moderate-severe pulmonary hypertension?
Yes
No
c. List medications currently used to control CHD __________________________________________________________
Congenital abnormality of respiratory system — 748.3 to 748.4 (specify ICD-9 code) __________________________
Severe neuromuscular disease that compromises mobilization of resp. secretions (specify ICD-9 code) _________
Other diagnosis (specify ICD-9 code) _________________________________________________________________
Prescription information
®
Synagis
(palivizumab): 50mg and/or 100mg vials and 10mL sterile water for injection
Sig: Reconstitute as directed and give 15 mg/kg intramuscular injection once per month
Dispense quantity __________ Refill x _______month(s) Choose one:
Dispense as written
Substitution allowed
Physician’s signature _________________________________________________________________________________
Complete the following section only if gestational age is 32 to < 35 weeks and patient is under 3 months old.
Day care. Attends day care:
No
Yes: Name of day care ___________________________ # of days/week ______
Siblings. Please list number of siblings and their age(s) _____________________________________________________
Fax completed form to 215-761-9165. Your office will receive a response by fax within two business days.
02/2011 INJ-006
Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company,
and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.

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