Navitus Texas Medicaid Palivizumab (Synagis) Prior Authorization Request Form
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2Palivizumab (Synagis) Prior Authorization Request Form
NAVITUS TEXAS MEDICAID
Prescribing practitioner should FAX completed form to the dispensing PHARMACY
Patient’s Name
Client ID:
Date of Birth:
/
/
County of residence:
Telephone Number:
Address:
City:
State:
ZIP:
Parent/Legal Guardian (if applicable):
Age in months as of October 1:
Estimated gestational age at birth:
____ and ____/7 weeks
Requested dates of service—From:
To:
Quantity Requested (doses):
Choose one of the following:
□
Date of birth on or after 09/30/2010
□
¥
Active diagnosis of hemodynamically significant
heart disease (ICD-9-CM code:__________)
¥
nd
Clients who are younger than 24 months
(NOTE: This excludes infants with hemodynamically insignificant
heart disease – Refer to 2
page for list)
chronological age at the start of the RSV
□
Active diagnosis of chronic lung disease of infancy (CLDI)* (ICD-9-CM code:__________) and required any of the
season can qualify, for up to 5 monthly doses
following therapies within the past 6 months:
of palivizumab, based on the criteria to the
right. Diagnoses and conditions must be
□
□
Supplemental oxygen
Diuretics
clearly documented in the client’s
□
□
Chronic corticosteroids
Long-term mechanical ven
t ilation
medical record.
* CLDI was formerly called “bronchopulmonary dysplasia.” It can develop in pre-term neonates who are treated
(Refer to the Texas Medicaid Provider
with oxygen and positive pressure ventilation. Many cases are seen in infants who previously had respiratory
Procedures Manual for more details about
distress syndrome (RDS). CLDI is not asthma, croup, a recurrent upper respiratory infection, chronic bronchitis,
congenital heart and chronic lung disease
chronic bronchiolitis, or a history of a previous RSV infection.
diagnoses.)
□
Solid organ or stem cell transplant recipient (ICD-9-CM code:__________)
¥
nd
Refer to the 2
page for additional
NOTE: As there is limited data on effectiveness of palivizumab in the second year of life, decision about initiating
information.
palivizumab on children born before 9/30/2011 should be made in consultation with an appropriate pediatric
subspecialist.
¥
Date of subspecialist
consultation w/recommendation for palivizumab for current RSV season
Name of subspecialist:
¥
Specialty of Subspecialist
:
Choose one of the following:
□
Date of birth on or after 09/30/2011
□
≤ 28 6/7 weeks gestational age at birth (ICD-9-CM code:__________)
Clients who are younger than 12 months
□
Severe congenital abnormality of airway OR severe neuromuscular disease that compromises handling of
chronological age at the start of the RSV
respiratory tract secretions (ICD-9-CM code:__________)
season can qualify, for up to 5 monthly doses
□
Cystic Fibrosis with BMI<25%ile and/or chronic lung disease (ICD-9-CM code:__________)
of palivizumab, based on criteria to the right.
□
□
Date of birth on or after 03/31/2012
< 31 6/7 weeks gestational age at birth (ICD-9-CM code:__________)
□
□
Date of birth on or after 7/30/2012 can
>32 0/7 and <34 6/7 weeks gestational age AND one of the follow two risk factors
qualify for up to 3 monthly doses of
□
Attends child care facility with other infants and toddlers
palivizumab up until they reach 90 days of age
□
Has older sibling < 5 y.o. living in same household
based on criteria to the right.
Current clinical information and diagnoses that pertain to medical necessity (if necessary, and additional pages):
Rx: Synagis ® (palivizumab) Liquid Solution 50mg and/or 100mg vials
Sig: Inject 15mg/kg one time per month
Quantity: QS for weight based dosing
_______________ (kg)
Refills: _________________
□
□
□
Syringes 1ml 25G 5/8”
Syringes 3ml 20G 1”
Epinephrine 1:1000 amp.
Sig: Inject 0.01mg/kg as directed
□
□
Other:
Known Allergies:
Physician Name (printed):
Date:
/
/
Address:
City:
State:
ZIP:
Telephone Number:
Fax Number:
TPI:
NPI:
Taxonomy
Benefit Code:
Physician Signature:
License number:
Dispensing Pharmacy FAX completed form to NAVITUS for approval: 1.855.668.8553
PH-0812-016
Effective date 09012012
Reference: American Academy of Pediatrics Committee on Infectious Diseases Modified Recommendations for Use of Palivizumab for Prevention of Respiratory
Syncytial Virus Infections. Pediatrics Vol. 124 No. 6 December 1, 2009 pp. 1694 -1701
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