Prior Authorization Synagis 2018-2019

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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 with NO decimals
    Codes must be 3 - 8 characters and no decimals.
  • Has the patient been using samples?
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  • Dose and Directions: *

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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: *

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

Secondary Diagnosis/ICD-10:

  • Accredo:
    Phone: 877-259-2295
    Fax: 888-773-7386
  • Other:

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

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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 11-1-17 < 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
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Blue Cross and Blue Shield of Kansas City
Pharmacy Services
P.O. Box 412735
Kansas City, MO 64141-2735

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Revised 09/26/18

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