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  • 21 check-boxes
  • 73 other fields

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Prior Authorization Request Form
Universal Synagis®
Form must be complete, correct, and legible or the PA process can be delayed.
Use one form per member, please.
Request Date:
*Fax the COMPLETED form or call the plan with the requested information.
Absolute Total Care
P: 866-433-6041
F: 855-865-9469
FFS Medicaid
P: 866-247-1181
F: 888-603-7696
First Choice
P: 866-610-2273
F: 866-610-2775
Healthy Blue
by Blue Choice of SC
P: 866-902-1689
F: 800-823-5520
Molina Healthcare
P: 855-237-6178
F: 855-571-3011
WellCare
Health Plan
P: 888-588-9842
F: 866-354-8709
I. MEMBER INFORMATION
First Name Last Name
Medicaid ID # Date of Birth (MM/DD/YYYY) Sex
Male
Female
II. PRESCRIBER’S INFORMATION
Prescriber’s First Name Prescriber’s Last Name
National Provider ID # (NPI) DEA Number
Prescriber’s Phone Number Prescriber’s Fax Number
III. PHARMACY INFORMATION
Name of Dispensing Pharmacy NPI #
Pharmacy Phone Number Pharmacy Fax Number
IV. DRUG INFORMATION
Strength:
50 mg (NDC 60574-4114-01)
Quantity:
PA Start Date:
100 mg (NDC 60574-4113-01)
Quantity:
PA Start Date:
V. CLINICAL CRITERIA DOCUMENTATION (**Do NOT include documentation that is not requested on this form**)
1. What was the patient’s gestational age at birth?
weeks
days
ICD Diagnosis Code:
2. What is the patient’s current weight?
kg
lb
3. Does the patient have Chronic Lung Disease of Prematurity (formerly called bronchopulmonary dysplasia)?
Yes (go to question 4) No (go to question 6)
4. Did the patient receive oxygen immediately following birth?
Yes (go to question 5) No (go to question 6)
Revised: October 8, 2018
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Prior Authorization Request Form
Universal Synagis
Form must be complete, correct, and legible or the PA process can be delayed.
Use one form per member, please.
5. Indicate the % oxygen received, date received, and the duration of treatment:
6. Indicate if patient is receiving any of the following respiratory support therapies on a daily basis:
Systemic corticosteroids Most recent date:
Diure
tics Most recent date:
Bronchodilator Most recent date:
Oxygen Most recent date:
7. Does the patient have a diagnosis of Cystic Fibrosis?
Yes
No
If yes, submit documen
tation of pulmonary and nutritional status
8. Does the patient have any of the following?
Anatomic Pulmonary Abnormality. Please specify:
Neuromuscular Disorder. Please specify:
9. Does the patient have any of the following?
HIV
Cancer, receiving chemotherapy
Organ transplant, receiving immunosuppressant therapy
Other medical condition that is severely immunocompromising patient (e.g., Children younger than 24 months who will be profoundly
immunocompromised during the RSV season).
Please specify:
10. Has this patient received a heart transplant?
Yes
No
Date:
11. Does patient have he
modynamically significant congenital heart disease?
Yes
No
Please indicate:
Acyanotic heart dise
ase Most recent date:
Cyanotic heart disease Specify: Name of Pediatric Cardiologist:
Pulmonary Hypertension
Other:
12. Will this patient’s congenital heart disease require cardiac surgery?
Yes
No
13. Please list any medications that may be used:
Ace-Inhibitor/ARB
Most recent date administered:
Diuretic Most recent date administered:
Beta-blocker Most recent date administered:
Digoxin
Most recent date
administered:
Other cardiovascular medications. Please
specify:
14. Please note any other information pertinent to this PA request:
Prescriber Signatu
re (Required) Date
(**On behalf of the Prescriber or Pharmacy Provider, I ** certify that the information stated above is a true statement,
made for the purpose
s of inducing SC Medicaid to offer prescription coverage to this individual for the medication
requested above. I understand that this document and any attached materials will be retained for the purposes of possible
future audit).
Revised:
October 8, 2018
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Completed 5 May 2021

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