Blue Cross Blue Shield of Texas - Synagis Request Online Form

Welcome, Providers			Company Information

Provider Finder

Provider
Library

Forms

Electronic
Commerce

General Reimbursements

Blue Review

Synagis Request Online 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^*

Gender

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, 6 days and <12 months of age at the start of RSV season

Gestational age of 29 weeks, 0 days to 31 weeks, 6 days and <6 months of age at the start of RSV season

Gestational age of 32 weeks, 0 days to 34 weeks, 6 days and <3 months at the start of RSV season, AND clinically has the following risk factors (Check all that apply)

Sibling(s) younger than age 5
Child Care Attendance
None

Gestational age of ≤34 weeks, 6 days and <12 months of age at the start of RSV season, with diagnosis of:

Severe neuromuscular disease
Congenital abnormality of airway

4. Diagnosis of severe immunodeficiency and less than 24 months of age?	Yes No
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 07/2009