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Synagis Request Online Form

STATEMENT OF MEDICAL NECESSITY
RESPIRATORY SYNCYTIAL VIRUS (RSV) PROPHYLAXIS

* Required fields

PATIENT INFORMATION
Gender   
  
INSURANCE INFORMATION
PHYSICIAN INFORMATION
CLINICAL INFORMATION
PRIMARY DIAGNOSIS
 
(weeks/days)
(Check all that apply)*

  
  
  
  
  
  
  
  
  
  
  
  
   
   

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

  
  

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

  Date:  
  Date:  
  Date:  
  Date:  

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

  
  

Diagnosis of moderate-severe pulmonary hypertension?

  
  

   

Date last received:  

3. Prematurity:

  

  

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
 

4. Diagnosis of severe neuromuscular disease or congenital abnormality of the airway which compromises handling respiratory secretions and less than 12 months of age?


5. Diagnosis of severe immunodeficiency and less than 24 months of age?


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 08/2011

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
® Copyright 2011. Health Care Service Corporation. All Rights Reserved.

SM Service Mark of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

Blue Cross and Blue Shield of Texas refers to HCSC Insurance Services Company, which is a wholly owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for stand-alone prescription drug plans with a Medicare contract under contract number S5715 with the Centers for Medicare and Medicaid Services.

A stand-alone prescription drug plan with a Medicare contract.