Prior Authorization Synagis 2019-2020

Loading...

Loading...

* Required Field

Enter Patient Information

  • Drug Name: *
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Date of Birth: *
  • Patient Group ID: *
  • ICD-10 Diagnosis Codes: *
  • Diagnosis Codes must be 3-8 characters along with decimals
    Codes must be 3 - 8 characters and 2 decimals.
  • Has the patient been using samples?
  • Yes No
  • Dose and Directions: *

* Required Field

Enter Provider Information

  • Provider ID OR NPI: *
  •   
  • Provider's Name: *
  • Physician's Specialty: *
  • Street Address: *
  • City: *
  • State: *
  • ZIP Code: *
  • Email Address:
  • Phone Number:
  • Enter a 10 digit phone number.
  • Fax Number:*
  • Enter a 10 digit phone number.
  • Contact First Name: *
  • Contact Last Name: *
  • Contact Email Address: *
  • Contact Phone Number: *
  • Contact Phone Ext:
  • Contact Fax Number:*

NOTE: Each unit of 90378 = 50 mg

  • Gestational age: *weeks days
  •   
  • Chronological age: *weeksdays
  •   
  • Birth Weight: * kg lbs
  •   
  • Current Weight: *kglbs
  •   

DX: *

Please Note: decimals are required in the ICD-10 Code

  • Congenital heart disease ICD-10 (include decimals)
    Please enter ICD-10 Code along with decimals.
  • Chronic respiratory disease arising in the perinatal period (CLD) ICD-10
    Please enter ICD-10 Code along with decimals.
  • Other respiratory conditions of fetus/newborn ICD-10
    Please enter ICD-10 Code along with decimals.
  • Congenital anomalies of the respiratory system ICD-10
    Please enter ICD-10 Code along with decimals.
  • Other
    Please enter Other Choice.
    ICD-10:
    Please enter ICD-10 Code along with decimals.

Secondary Diagnosis/ICD-10:

  • Optum Specialty Services
    Phone:855-427-4682
    Fax: 800-218-3221
  • Other:

If you have any additional information pertinent to this patient’s therapy, please specify.

Insert Attachments.

Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







Medical Criteria:

(Please check the appropriate boxes UNDER APPROPRIATE GESTATIONAL AGE and provide documentation as requested below)

Gestational Age < 29 wks < 32 wks N/A N/A
Chronological age as of 11-1-19 < 12 mos < 24 mos < 12 mos < 24 mos
   
   
Preterm infants with chronic lung disease of prematurity who required >21% O2 for at least the first 28 days after birth
Congenital airway abnormality that impairs the ability to clear secretions from the upper airway because of ineffective cough specify
Severe neuromuscular disease that impairs the ability to clear secretions from the upper airway because of ineffective cough specify
Hemodynamically significant acyanotic congenital heart disease requiring surgery
Cyanotic heart defects with recommendation from pediatric cardiologist
Pulmonary Hypertension
Cystic fibrosis with clinical evidence of CLD and/or nutritional compromise
Cystic fibrosis with manifestations of severe lung disease (persistent abnormalities on chest X-ray or CT) or weight for length less than the 10th percentile
Prophylaxis after surgical procedure requiring Cardiopulmonary Bypass
Cardiac transplantation
Treatment for chronic lung disease of prematurity
5 dose max 5 dose max 5 dose max 5 dose max
Required Documents: * NICU Discharge Summary NICU Discharge Summary and clinical notes from the pediatric specialist NICU Discharge Summary Clinical notes from the pediatrician/specialist including treatments for the last 6 months
  • Checking this box will send a copy of your form to the email address provided.

If you experience issues submitting this form, please try again later.

Or, print the form and mail to:

Blue Cross and Blue Shield of Kansas City
Pharmacy Services
P.O. Box 412735
Kansas City, MO 64141-2735

Cancel

Revised 01/01/2020

Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

Are you having an issue with this eForm? If so click here to send us some feedback that can aide in making your experience better.