Continued
2020-2021 Synagis
®
Seasonal Respiratory Syncytial Virus Enrollment Form
Please complete Patient and Prescriber information
Patient Name: ________________________________ Patient DOB: ________________________________
Prescriber Name: _____________________________ Prescriber Phone: ____________________________
4a DIAGNOSIS AND CLINICAL INFORMATION
Patient’s Gestational Age (required): _______ w eeks _______ days Patient’s Birth Weight: __________ g / kg / lbs (please circle)
Current Weight: __________ g / kg / lbs (please circle) Date Recorded: ___/___/______
Did patient receive Synagis last season? No Yes Dates of Synagis doses given this season: _________________________
Multiple births: No Yes Enter names of Synagis candidates (submit separate enrollment forms): ________________________
Daycare attendance: No Yes School-age siblings in home: No Yes
NICU history: No Yes If yes, NICU name and include NICU summary: ____________________________________________
Allergies: __________________________________ Medical conditions not listed below : __________________________ ________
Clinical Conditions: 2014 AAP Committee on Infectious Disease and Bronchiolitis Guidelines
Chronic Lung Disease (CLD):
< 12 months of age w ith CLD*
< 24 months of age w ith CLD* AND continues to require medical support during the 6-month period before second RSV season AND
Supplemental oxygen (dates) ___________________ Chronic corticosteroids (drugs/dates) ____________________
Diuretic therapy (drugs/dates) ____________________ Bronchodilators (drugs/dates) __________________________
*CLD of prematurely defined as gestational age < 31 w eeks, 6 days AND requirement for 21% oxygen for at least the first 28 days after birth
Congenital Heart Disease (CHD):
< 12 months of age at start of season w ith hemodynamically significant CHD such as:
Acyanotic heart disease and receiving medication to control congestive heart failure and surgery to correct
(meds/dates) ____________________ (surgery date) ____________________
Moderate to severe pulmonary hypertension
Other: describe ____________________________________________________________________________
< 24 months of age undergoing cardiac transplantation during the RSV season (date) ____________________
Cyanotic Heart Disease: diagnosis ____________________
Airw ay/Neuro-muscular Conditions:
< 12 months of age at start of season and compromised handling of secretions AND due to
Significant abnormality of the airw ay (attach clinical notes) Neuromuscular condition (attach clinical notes)
Prem aturity: < GA 28 w ks, 6 days AND < 12 months at start of season
Other conditions: Other medical history (describe) _________________________________________________________________
5 PRESCRIPTION INFORMATION
50 mg and/or 100 mg vials
Inject 15 mg/kg IM one time per month
Other: ____________________________
Quantity: QS to
achieve 15 mg/kg dose
Refills:_____________
Inject 0.01 mg/kg SC as directed for
anaphylaxis
Quantity:___________
Refills: 0
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
6 PHYSICIAN SIGNATURE REQUIRED
PRODUCT SUBSTITUTION PERMITTED (Date)
x_______________________________________
DISPENSE AS WRITTEN (Date)
x_____________________________________
The information provided above is true and accurate to the best of my knowledge, with supporting documentation in the patient’s medical record. By signing
below, I hereby authorize CVS Specialty Pharmacy and/or its affiliate pharmacies to complete and submit prior authorization (PA) requests to payors for the
prescribed medication for this patient and to attach this Enrollment Form to the PA request as my signature.
CONFIDENTIALITY NOTICE: This communication and any attachments may contain confidential and/or privileged information for the use of the designated
recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any
review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have rece ived this communication in error, please notify the
sender immediately by telephone and destroy all copies of this communication and any attachments.
Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members’ private health information.
This document contains references to brand -name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not
affiliated with CVS Specialty and/or one of its affiliates.
©2020 CVS Specialty and/or one of its affiliates. 75-38382A 082620
Patient is interested in patient support programs STAMP SIGNATURE NOT ALLOWED Ancillary supplies and kits provided as needed for administration
6 PHYSICIAN SIGNATURE REQUIRED
PRODUCT SUBSTITUTION PERMITTED (Date)
x_______________________________________
DISPENSE AS WRITTEN (Date)
x______________________________________
