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Synagis
®
(palivizumab) Injectable
Medication Precertification Request
Aetna Precertification Notification
Phone: 1-866-752-70
21
FAX: 1-888-267-3277
For Medicare
Advantage Part B:
Please Use Medicare Request Form
(All fields must be completed and legible for precertification review)
Please indicate:
Start of treatment: Start date / /
Continuation of therapy: Date of last treatment / /
Precertification Requested By: Phone: Fax:
A. PATIENT INFORMATION
First Name: Last Name: DOB:
Address: City: State: ZIP:
Home Phone: Work Phone: Cell Phone: E-mail:
Current Weight: lbs or kgs Height: inches or cms
Allergies:
B. INSURANCE INFORMATION
Aetna Member ID #:
Group #:
Insured:
Does patient have other coverage? Yes No
If yes, provide ID#: Carrier Name:
Insured:
Medicare: Yes No If yes, provide ID #:
Medi
caid: Yes No If yes, provide ID #:
C.
PRESCRIBER INFORMATION
First Name: Last Name: (Check One): M.D. D.O. N.P. P.A.
Address: City: State: ZIP:
Phone: Fax:
St Lic #: NPI #: DEA #: UPIN:
Provider E-mail:
Office Contact Name:
Phone:
Specialty (Check one): Primary Care (Pediatrician) Other:
D. DISPENSING PROV
IDER/ADMINISTRATION INFORMATION
Place of Administration:
Physician’s Office
Outpatient Infusion Center Phone:
Center Name:
Home Infusion Center Phone:
Agency Name:
Administration code(s) (CPT):
Address:
Dispensing Provider/Pharmacy: (Patient selected choice)
Physician’s Offi
ce Retail Pharmacy
Specialty Pharmacy O
ther:
Name:
Address:
Phone: Fax:
TIN: PIN:
E. PRODUCT INFORMATION
Request is for Synagis
®
: 15mg/kg IM one time per month (every 30 days) Other:
F. DIAGNOSIS INFORMATION - Please indicate primary ICD code and specify any other where applicable.
Primary ICD code: Secondary ICD code: Other ICDCode:
G. CLINICAL INFORMATION - Required clinical information must be completed in its entirety for all precertifica
tion requests.
For ALL requests (clinical documentation must be submitted):
Gestational Age at Birth (weeks) (days)
Is the requested drug being used to prevent serious lower respiratory tract disease caused by RSV? Yes No
Does the patient have a diagnosis of prematurity (defined as gestational age ≤ 28 weeks, 6 days)?
Yes No
Is this an off-season request for the requested drug? Yes No
According to the CDC National Respiratory and Enteric Virus Surveillance System (NREVSS), is the RSV activity ≥ 10% (with rapid antigen
testing) or ≥ 3% (with real-time polymerase chain reaction (PCR) test) for the requested region within 2 weeks of the intended dose?
Yes No
How many doses of the requested drug has the patient received this RSV season? Yes No
Chronic Lung Disease of Prematurity:
What was the patient’s gestational age? <31 weeks, 6 days >32 weeks, 0 days
What is the patient’s chronological age at the start of RSV season? <12 months of age
Did the patient receive the requested drug during the previous
RSV season?
Yes No
12 to <24 months of age
>24 months of age
Does/Did the child require greater than 21% oxygen for at least the first 28 days after birth
? Yes No
Does the child continue to require medical support during the 6 month period prior to the start of the RSV season? Yes
Please indicate the medical therapy: Oxygen Diuretic Chronic corticosteroid
Other, please explain:
No
GR-68942 (8-21)
