Blue Cross Blue Shield of Texas - Synagis Request Form

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Synagis Request Form

STATEMENT OF MEDICAL NECESSITY
RESPIRATORY SYNCYTIAL VIRUS (RSV) PROPHYLAXIS

^* Required fields

PATIENT INFORMATION

Last Name^*

First Name^*

Middle Initial

Street Address

City

County

State

ZIP Code

Date of Birth^*

Sex	Male Female

Parent/Guardian

INSURANCE INFORMATION

Primary Insurance^*

Cardholder Name^*

Group Number^*

Policy Number^*

Insurance Telephone Number (+Area Code)

Secondary Insurance

Cardholder Name

Group Number

Policy Number

Insurance Telephone Number (+Area Code)

Employer

PHYSICIAN INFORMATION

Prescriber's Name^*

Hospital/Clinic^*

Office Contact^*

Email Address:^*
Address^*

City/State/ZIP^*

Telephone Number
(+Area Code)^*

Prescriber's License Number

DEA Number

Fax Number
(+Area Code)

NPI Number

Supervising Physician's Name
(If Required for Mid-Level Practitioner)

License Number

CLINICAL INFORMATION

PRIMARY DIAGNOSIS

Patient’s Gestational Age (GA)^*
(weeks/days)

Birth Weight - kg (lb)

Current Weight - kg (lb)

Date Recorded

(Check all that apply)^*

Congenital Heart Disease (745.0–747.9)
Chronic Respiratory Disease Arising in the Perinatal Period (CLD) (770.7)
≤24 weeks' GA (765.21–765.22)
25–26 weeks' GA (765.23)
27–28 weeks' GA (765.24)
29–30 weeks' GA (765.25)
31–32 weeks' GA (765.26)
33–34 weeks' GA (765.27)
35–36 weeks' GA (765.28)
37 or more week's GA (765.29)
Other Respiratory Conditions of Fetus and Newborn (770.0–770.9)
Congenital Anomalies of Respiratory System (748)
Other
Secondary diagnosis (if applicable)

MEDICAL CRITERIA

1. Diagnosis of chronic pulmonary disease (CLD/BPD) and less than 24 months of age?

Yes
No

Is patient receiving medical treatment for CLD/BPD (check all that apply and provide last date received):

Oxygen Date:
Corticosteroids Date:
Bronchodilator Date:
Diuretic Date:

2. Diagnosis of hemodynamically significant congenital heart disease and less than 24 months of age?

Yes
No

Diagnosis of moderate-severe pulmonary hypertension?

Yes
No

Medications for CHD:
Date last received:

3. Prematurity:

Gestational age of ≤28 weeks and <12 months of age at the start of RSV season
Gestational age of 29–32 weeks and <6 months of age at the start of RSV season
Gestional age of 32-35 weeks (i.e. between 32 weeks/1 day and 35 weeks/0 days) and <6 months at the start of RSV season, AND clinically has the following risk factors (Check all that apply)

School-age siblings up to age ten
Exposure to environmental air pollutants
- Specify type of pollutant(s)

Child care attendance
Severe neuromuscular disease
Congenital abnormality of airway
None

Other significant medical history:

EXPECTED DATE OF FIRST/NEXT INJECTION:
Injection already given?	Yes No If yes, date(s):
Deliver product to:	Office Patient's home Clinic Clinic Location:
Agency nurse to visit home for injection?	Yes No Agency Name:
RX
Synagis® (palivizumab) 50- and/or 100-mg vials and Sterile Water for injection 10 mL (for lyophilized formulation only)* Sig: Reconstitute as directed and inject 15 mg/kg IM one time per month (for lyophilized formulation only) OR Sig: Inject 15 mg/kg IM one time per month (for liquid formulation only) Dispense Quantity: QS Refill
Epinephrine 1:1000 amp. Sig: Inject 0.01 mg/kg as directed
Known Allergies:
Other:
Sig:
*Synagis® liquid formulation will be automatically substituted upon manufacturers’ market release.

	Updated 6-2008