Created: 08/31/16; Revised 08/20/20 Page 1 of 1
SYNAGIS (PALIVIZUMAB)
AUTHORIZATION FORM
This form must be completed by a person with thorough clinical knowledge of the member’s current clinical presentation and his/her treatment history.
The entire form must be completed as clearly and specifically as possible. Omissions, generalities, and illegibility will result in the form being returned for
further completion or clarification. Please fax this form and other relevant documents to (763) 847-4014.
Patient Name and ID# Patient DOB
Date/
s of Service
Settiing
Patient Gestational Age weeks days Dx/ICD-10
Prescriber Name Prescriber Phone
Pharmacy Name (if applicable)
NPI Pharmacy Phone Pharmacy Fax
Home Health Care Provider (HHC) Name (if applicable)
NPI HHC Phone HHC Fax
INDICATIONS - must have one of the following: A-F
[Note: RSV season is based on regional seasonality of the disease.]
Check
Box
A. Gestational age less than 29 weeks 0 days who is less than 12 months of age at the beginning of the RSV season
B. Chronic lung disease (CLD) of prematurity – must meet: 1, and either 2 or 3
1. Gestational age less than 32 weeks 0 days; and
2. Less than 12 months of age during the RSV season and requires greater than 21% oxygen for at least the first 28 days after birth; or
3. Between 12 to less than 24 months of age and required greater than 21% oxygen for at least the first 28 days after birth
still
requires medical support (eg, chronic corticosteroid therapy, diuretic therapy, or supplemental oxygen) during the 6-month period before
the start of the second RSV season.
C. Member diagnosed with hemodynamically significant congenital heart disease (CHD) – must meet: 1 or 2
1. INITIAL REQUEST (covers up to 5 doses) Less than 12 months of age,
born within 12 months of onset of the RSV season, with any of the
following (check box if applicable):
Acyanotic heart disease with both of the following:
• Member is receiving medication to control congestive heart
failure; and
• Member will require cardiac surgical procedures
Moderate to severe pulmonary hypertension
Cyanotic heart defects in the first year of life with documentation of
decision for prophylaxis made in consultation with a pediatric
2. ONE ADDITIONAL DOSE REQUEST (> than 5 doses) Less than 24
months of age, the prescriber is requesting one additional
postoperative dose of Synagis for prophylaxis, with any of the
following (check box if applicable):
Member has undergone cardiac transplantation during the RSV
season
Member has undergone cardiac bypass or after extracorporeal
membrane oxygenation during the RSV season
[Note: One additional dose will be approved if medically necessary.]
D. Member diagnosed with anatomic pulmonary abnormalities or neuromuscular disorders – must meet: both 1 and 2
1. Less than 12 months of age; and
2. Anatomic pulmonary abnormalities (eg, pulmonary malformations, tracheoesophageal fistula, conditions requiring tracheostomy) or
neuromuscular disorders (eg, cerebral palsy) impair the member’s ability to clear secretions from the upper airway because of ineffective
cough.
E. Member is profoundly immunocompromised (eg, solid organ transplantation, hematopoietic stem cell transplantation, severe combined
immunodeficiency syndrome)
and
is less than 24 months of age during the RSV season
F. Member diagnosed with cystic fibrosis – must meet: 1 or 2
1. Less than 12 months of age with evidence of CLD and/or nutritional compromise; or
2. Between 12 to 24 months of age – and one of the following: a or b
a. Manifestations of severe lung disease (ie, previous hospitalization for pulmonary exacerbation in the first year of life or abnormalities
on chest radiography or chest computed tomography that persist when stable); or
b. Weight for length that is less than the 10
th
percentile on the pediatric growth chart
DOSING
Dose Requested: mg Current Weight: kg
A dose of Synagis has been administered in an inpatient setting
YES – Indicate date dose was administered:
NO
Weight
Calculated Dose
(max wt.)
Dispense (vials)
[Note: The calculated dose of Synagis is 15mg/kg. This drug is
available only in 50mg and 100mg vials and costs approximately
$1,000 per 50mg. To limit/minimize potentially significant waste,
follow the table on the left, which shows a 10% difference in
allowed dose from the calculated dose.]
Office
Home Health Care
