2014-15 Season Fee-For-Service Medicaid Synagis Request Form Page 3

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Texas Medicaid/CHIP Vendor Drug Program
Fee-For-Service Medicaid Synagis® Request Form
2014-15 Season
Category
Subcategories
Chronic Lung Disease (CLD) of Prematurity *
Born < 32 week, 0 day gestational age who require >21% oxygen for at least 28
days after birth.
Pediatric Subspecialist ǂ
•
Neonatologist
•
Pediatric Intensivist
•
Pediatric Pulmonologist
•
Pediatric Cardiologist
•
Pediatric Infectious Disease Subspecialist
•
Hemodynamically significant heart disease
Congestive heart failure (CHF) requiring medication
•
Moderate to severe pulmonary hypertension
•
Unrepaired cyanotic congenital heart disease
The following groups of infants are NOT AT INCREASED risk of RSV and generally should not receive immunoprophylaxis:
•
1.
Hemodynamically insignificant heart disease
Secundum atrial septal defect
•
Small ventriculoseptal defect
•
Pulmonic stenosis
•
Uncomplicated aortic stenosis
•
Mild coarctation of the aorta
•
Patent ductus arteriosus
2.
Congenital heart disease adequately corrected by surgery which does not continue to require medication for congestive heart
failure
3.
Mild cardiomyopathy that does not require medical therapy for the condition
Note: Tobacco smoke exposure is not an indication for Synagis administration. Tobacco dependent parents should be offered tobacco
dependence treatment or referral for tobacco dependence treatment. 1-877-YES-QUIT (1-877-937-7848, ) is the Quitline
operated in Texas.
Rev. 09/2014
Page 3 of 3
File: vdp_dur_syngfv

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