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MEDICATION PRIOR AUTHORIZATION REQUEST FORM FAX this completed (Sunshine Health)

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MEDICATION PRIOR AUTHORIZATION REQUEST FORM
FAX this completed form to (866) 351-7388
Call (800) 460-8988 to request a 72-hour supply of medication.
Reset Form Print Form
Envolve Pharmacy Solutions will respond via fax or phone within 24 hours of receipt of all necessary information, expect
during weekends and holidays. For immediate response on weekends and holidays, NurseWise will answer your call.
SYNAGIS
®
– All Florida Regions Combined
Coverage Period: Based upon the specific region per the FLDOH website:
http://www.floridahealth.gov/diseases-and-conditions/respiratory-syncytial-virus/
Maximum number of doses: 5
Note: Form must be completed in full. An incomplete form may be returned.
Recipient’s Medicaid ID# Date of Birth (MM/DD/YYYY)
/ /
Recipient’s Full Name
Prescriber’s Full Name
Prescriber’s NPI
Prescriber Phone Number Prescriber Fax Number
- - - -
Synagis Vial Qty:
SIG: Inject 15 mg/kg IM once monthly
Start Date: _____________________ Refill(s): ____________mos
100 mg 50 mg
Birth Weight: ___________ lbs / kgs Current Weight: ___________ lbs / kgs
Gestational Age (GA) : ___________________
If < 24 months old
Cardiac transplant during RSV season
Already on prophylaxis and eligible; give post-op dose after cardiac bypass or after ECMO
Profoundly Immunocompromised (Specify Diagnosis Code)________________________________
If > 12 months old and < 24 months old
Cystic Fibrosis
AND: must meet at least one of the following criteria
Nutritional compromise (weight for length < 10
th
percentile)
Hospitalization for pulmonary exacerbation in first year of life
Chest X-ray or CT abnormalities that persist when stable
Chronic lung disease (GA < 32 weeks and required oxygen for at least first 28 days after birth)
(Specify Diagnosis Code) _____________________________________
AND: has required any of the following therapies within the past 6 months:
Supplemental oxygen Steroids (systemic or inhaled)
Mechanical ventilation Diuretics
*CLD is not asthma, croup, recurrent upper respiratory infections, chronic bronchitis, chronic bronchiolitis, or a history of a previous RSV
infection.
Page 1 of 2
MEDICATION PRIOR AUTHORIZATION REQUEST FORM
FAX this completed form to (866) 399-0929
OR Mail request to: Envolve Pharmacy Solutions PA Dept. | 5 River Park Place East, Suite 210 | Fresno, CA 93720
Call (800) 460-8988 to request a 72-hour supply of medication.
Envolve Pharmacy Solutions will respond via fax or phone within 24 hours of receipt of all necessary information, expect
during weekends and holidays. For immediate response on weekends and holidays, NurseWise will answer your call.
SYNAGIS
®
– All Florida Regions Combined
Coverage Period: Based upon the specific region per the FLDOH website:
http://www.floridahealth.gov/diseases-and-conditions/respiratory-syncytial-virus/
Maximum number of doses: 5
Note: Form must be completed in full. An incomplete form may be returned.
If ≤ 12 months old
Hemodynamically significant cyanotic or acyanotic congenital heart disease on medications to control CHF and will require surgery:
(Specify Diagnosis Code) ______________________
Moderate to severe pulmonary hypertension
If < 12 months old
< 29 completed weeks gestational age at birth (otherwise healthy)
Diagnosis Code: ICD 10: P07.21 – P07.26
Chronic lung disease* (GA < 32 weeks): (Specify Diagnosis Code) _____________________________________
AND: required supplemental oxygen (for at least first 28 days after birth)
*CLD is not asthma, croup, recurrent upper respiratory infections, chronic bronchitis, chronic bronchiolitis, or a history of a previous RSV
infection.
Severe neuromuscular disease
(Specify Diagnosis code) __________________________
Congenital anomalies of the airways
(Specify Diagnosis code) __________________________
Profoundly immunocompromised
(Specify Diagnosis code)__________________________
Cystic Fibrosis with CLD and/or nutritional compromise
Prescriber’s Signature: __________________________________________________________ Date: _____________________________
REQUIRED FOR REVIEW: Copies of medical records (e.g., diagnostic evaluations and recent chart notes), the most recent copies of related
labs, and supporting documentation for clinically appropriate submissions.
The provider must retain copies of all documentation for five years.
NOTE: Pharmacies should not submit separate claims for different dosage strength vials to be administered on the same date.
Only one compound claim submission will be necessary. For example, if the Synagis dosage is 150 mg, the pharmacy should
submit a compound claim that lists the two different strength vials (100 mg and 50 mg).
Weight Criteria for Synagis
®
(palivizumab): (Refer to Weight Change Form)
All weights must be verified for dosing accuracy.
Page 2 of 2
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Completed 31 January 2021

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