2014-15 Season Fee-For-Service Medicaid Synagis Request Form (Page 2 of 3) in pdf

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Texas Medicaid/CHIP Vendor Drug Program

Fee-For-Service Medicaid Synagis® Request Form

2014-15 Season

Section I – Dispensing Pharmacy Information

Pharmacy Name

Maxor Specialty

Phone

866-629-6779

Fax

866-217-8034

Section II – Patient Demographics

Name

Medicaid ID

Date of Birth

Gestational Age

____ weeks and ____/ 7th day

Patient Phone

Address

County of residence

Has patient received a Synagis prophylactic injection during hospitalization since the start current of the RSV season?

Yes

If yes, number of shots: __________ Dose (mg): __________

Date: __________

Section III – Patient Diagnosis

Patients who are younger than 24

24-1: Active diagnosis of chronic lung disease (CLD) of prematurity*

months chronological age at the start of the

AND required any of the following therapies within the 6 months prior to the current RSV season

RSV season can qualify, for up to 5 monthly

(check all that apply): ICD-9-CM code:

doses of Synagis, based on the criteria listed

to the right. Diagnoses and conditions must

Chronic systemic corticosteroids

Diuretics

be clearly documented in the client’s medical

21%Supplemental oxygen

Long-Term Mechanical Ventilator

record.

Bronchodilator therapy

24-2: Profoundly immunocompromised during the RSV season (solid organ or hematopoietic

*Refer to page 3 for definition.

stem cell transplant, chemotherapy or other condition that leaves the infant profoundly

immunocompromised):

ICD-9-CM code:

12-1: ≤ 28 6/7 weeks gestational age at birth:

Patients who are younger than 12

ICD-9-CM code:

months chronological age at the start of the

12-2: Chronic lung disease (CLD) of prematurity:

ICD-9-CM code:

RSV season can qualify, for up to 5 monthly

doses of Synagis, based on criteria listed to

12-3: Severe congenital abnormality of airway OR severe neuromuscular disease that impairs the

the right.

ability to clear secretions from the upper airway because of ineffective cough:

ICD-9-CM code:

12-4: Active diagnosis of hemodynamically significant heart disease:

ICD-9-CM code:

AND

CHF on medication

Moderate to severe Pulmonary Hypertension OR

Cyanotic heart disease (in consultation with a pediatric cardiologist)

(NOTE: This excludes infants with hemodynamically insignificant heart disease - refer to page 3 for list)

Patients who are younger than 6 months

6-1: < 31 6/7 weeks gestational age at birth:

ICD-9-CM code:

chronological age at the start of the RSV

season can qualify, for up to 5 monthly doses

of Synagis, based on criteria to the right.

Section IV – Other Condition(s)

Synagis is prescribed by or in consultation with an appropriate Pediatric Subspecialist ǂ for a patient younger than 24 months of age with

conditions other than the criteria listed in Section III. (ǂ Refer to page 3 for a list of appropriate Pediatric Subspecialty.)

Subspecialist: _________________________

Subspecialty: _________________________

Date: _______________

Important note: Monthly prophylaxis should be discontinued in any child who experiences a breakthrough RSV hospitalization.

Section V – Synagis Prescription (to be completed by prescriber)

Rx:

Synagis (palivizumab) Liquid Solution vial

Quantity:________

Dose (mg): ________

Refills: ________

Sig:

Inject 15mg/kg one time per month

Current Weight:__________ (kg) or (lbs.)

Syringes 1ml 25G 5/8”

Syringes 3ml 20G 1”

Epinephrine 1:1000 amp.

Sig: Inject 0.01mg/kg as directed.

Prescriber Name

Date

Phone

Fax

Address, City, State & ZIP

NPI

Physician Signature:

License number:

Rev. 09/2014

Page 2 of 3

File: vdp_dur_syngfv

2014-15 Season Fee-For-Service Medicaid Synagis Request Form Page 2

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