Fillable Authorization Request (Synagis) (Sanford Health Plan)

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Authorization Request (Synagis) (Sanford Health Plan)

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The Authorization Request (Synagis) (Sanford Health Plan) form is 2 pages long and contains:

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  • 41 check-boxes
  • 40 other fields

Country of origin: US
File type: PDF

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Questions? Contact Pharmacy Management at (855) 305-5062 | TTY/TDD (877) 652-1844
For free translation service, call (800) 892-0675
HP-3340 10-19
Prescription Drug Prior
Authorization Request (Synagis)
FAX TO (701) 234-4568
PO Box 91110
Sioux Falls, SD 57109-1110
Toll-Free: (855) 305-5062
TTY/TDD: (877) 652-1844
Fax: (701) 234-4568
INSTRUCTIONS:
1. All fields must be completed and legible for review.
2. The Plan’s decision will be based on individual plan policy and clinical documentation submitted.
3. Fax completed form to the number above, or submit online through your provider portal at
sanfordhealthplan.com/providerlogin. Prior authorizations cannot be completed over the phone.
4. If approved, Sanford Health Plan will cover up to 5 doses, to be given between November 15
th
of
the current year through April 15
th
of the following year.
5. Questions? Contact Pharmacy Management Department at (855) 305-5062.
Please check the appropriate box below. This form is being used for:
☐
Formulary Exception
☐ Prior Authorization (PA) Request
☐ Unsure/Unknown
Member Information
Member’s Gestational Age:
_______________ Weeks ____________ Days
Member’s Current Weight:
_______________ kg ____________ Date Recorded
Diagnosis
PRIMARY DIAGNOSIS (ICD-10 CODE): SECONDARY DIAGNOSIS (ICD-10 CODE):
DESCRIPTION:
DESCRIPTION:
Prescription Drug Information
Medication being
requested:
Strength:
Quantity:
Day’s Supply:
HCPC
(if applicable):
Directions
for use:
Requested therapy medication is:
☐ New ☐ Continuation of therapy
** If continuation,
provide start date:
Medical rationale for use:
Expected length of therapy:
Check here if this request is for retroactive coverage for a previous
claim or date of service. Date of service: ________________________
Provider Information
How will medication be obtained?
Prescriber name (first & last):
☐ MD
☐ DO
☐ PA
☐ NP
☐ APRN
☐ _________
Buy and Bill
Tax ID:
Facility Name:
Specialty:
NPI #:
Address:
City, State, Zip:
Address:
Pharmacy
Tax ID:
City, State, Zip:
Pharmacy
Name:
Phone:
Fax:
Is home health requested?
Contact person at
provider’s office:
Yes
No
Agency
Name:
Questions? Contact Pharmacy Management at (855) 305-5062 | TTY/TDD (877) 652-1844
For free translation service, call (800) 892-0675
HP-3340 10-19
Clinical Information Submitted for Determination
To provide required information, attach additional sheets, lab results, and other supporting documentation
as necessary. Denote which pages of the records to review to help expedite the review process.
Preterm Infants without Chronic Lung Disease of Prematurity or Congenital Heart Disease
Risk factors?
☐
Young chronological age < 12 weeks
☐ Severe neuromuscular disease
☐ Congenital abnormality of the airway
☐
Exposure to environmental air pollutants
☐
Preschool or school aged siblings
☐ Daycare attendance outside the home
☐ RSV activity per CDC National Respiratory
and Enteric Virus Surveillance System > 10 %
Provide a letter of medical necessity from two (2) of the following three
(3) subspecialties:
1. Pediatric Infectious Disease 2. Neonatology 3. Pediatric Pulmonology
Attach Documentation
Preterm Infants with Chronic Lung Disease of Prematurity
Did the infant require > 21 % oxygen for at least the first 28 days after
birth?
☐
Yes
☐ No
If yes, provide clinical documentation to support the use of > 21 %
oxygen for at least the first 28 days after birth.
Attach Documentation
In the past 6 months, has the infant required any of the following: chronic
corticosteroid therapy, diuretic therapy, or supplemental oxygen?
☐
Yes
☐ No
If yes, provide clinical documentation or pharmacy records to
support the use of one or more of the above.
Attach Documentation
Infants with hemodynamically significant congenital heart disease (CHD)
List medication(s) infant is on to control congestive heart failure or
pulmonary hypertension.
Will the infant require cardiac surgical procedures?
☐
Yes
☐
No
Does the infant have moderate-to-severe pulmonary hypertension?
☐
Yes
☐
No
Has or will the infant undergo cardiac transplantation during the RSV
season?
☐
Yes
☐ No
Provide a letter of medical necessity from a pediatric cardiologist. Attach Documentation
Children with anatomic pulmonary abnormalities or neuromuscular disease
Provide clinical documentation that the infant has neuromuscular
disease or congenital abnormality that impairs the ability to clear
secretions from the upper airway.
Attach Documentation
Immunocompromised Children
Provide clinical documentation supporting that the infant is profoundly
immunocompromised.
Attach Documentation
Children with Cystic Fibrosis
In the past 6 months, has the infant required any of the following: chronic
corticosteroid therapy, diuretic therapy, or supplemental oxygen?
☐
Yes
☐ No
If yes, provide clinical documentation or pharmacy records to
support the use of one or more of the above.
Attach Documentation
Has the infant been hospitalized in their first year of life for pulmonary
exacerbation?
☐
Yes
☐ No
Does the infant have abnormalities on chest radiography or chest
computed tomography that persist when stable?
☐
Yes
☐ No
Is the infant’s weight less than the 10
th
percentile?
☐
Yes
☐
No
Prescriber signature (same as prescriber listed above):
Date Submitted:
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Authorization Request (Synagis) (Sanford Health Plan)

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Completed 20 May 2021

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