"Synagis Pharmacy Prior Authorization Form" - Colorado

Synagis Pharmacy Prior Authorization Form is a legal document that was released by the Colorado Department of Health Care Policy and Financing - a government authority operating within Colorado.

Form Details:

  • Released on October 11, 2018;
  • The latest edition currently provided by the Colorado Department of Health Care Policy and Financing;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Department of Health Care Policy and Financing.

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Synagis Pharmacy Prior Authorization Form
(For home administration use only, not physician office or outpatient)
Request Date: 
 
MEMBER INFORMATION
LAST NAME:
FIRST NAME:
HEALTH FIRST COLORADO ID NUMBER:
DATE OF BIRTH:
 
GENDER:
Male
Female
CURRENT WEIGHT:
kg
 
UNITS PER MONTH:
0
OR
1 X 50MG
X 100MG
NUMBER OF MONTHS REQUESTED (NO MORE THAN 5):
TODAY’S DATE:
DATES OF SERVICE:
FROM:
TO:
PROVIDER INFORMATION
PHYSICIAN LAST NAME:
PHYSICIAN FIRST NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP:
PHONE
NUMBER:
FAX NUMBER:
PHYSICIAN NPI NUMBER:
DEA NUMBER:
Health First Colorado will approve Synagis
®
prior authorization requests for members under the age of two, at the start of
the current RSV season, who meet one of the following conditions. Requests will be approved for a maximum of 5
doses, at a dosing interval of no fewer than 26 days between refills. Requests will be accepted beginning
November 12, 2018, prior to the season start date of November 26, 2018. Do not submit requests prior to November 12,
2018.
at least
For infants in the first year of life: (Check
one of the following AND indicate diagnosis code)
Any infant up to 12 months of age, born before 29 weeks 0 days gestation.
For infants born before 32 weeks 0 days gestation AND Chronic Lung Disease
(CLD) of prematurity with greater than 21% oxygen use for at least 28 days
ICD 10-CM
after birth
Code:
An infant with cystic fibrosis with clinical evidence of CLD AND/OR nutritional
ICD 10-CM
compromise
Code:
An infant with neuromuscular disease or pulmonary abnormality AND is unable
ICD 10-CM
to clear secretions from the upper airways
Code:
An infant who undergoes cardiac transplantation during the RSV season.
ICD 10-CM
Code:
Revision Date: 10/11/2018 
Synagis Pharmacy Prior Authorization Form
(For home administration use only, not physician office or outpatient)
Request Date: 
 
MEMBER INFORMATION
LAST NAME:
FIRST NAME:
HEALTH FIRST COLORADO ID NUMBER:
DATE OF BIRTH:
 
GENDER:
Male
Female
CURRENT WEIGHT:
kg
 
UNITS PER MONTH:
0
OR
1 X 50MG
X 100MG
NUMBER OF MONTHS REQUESTED (NO MORE THAN 5):
TODAY’S DATE:
DATES OF SERVICE:
FROM:
TO:
PROVIDER INFORMATION
PHYSICIAN LAST NAME:
PHYSICIAN FIRST NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP:
PHONE
NUMBER:
FAX NUMBER:
PHYSICIAN NPI NUMBER:
DEA NUMBER:
Health First Colorado will approve Synagis
®
prior authorization requests for members under the age of two, at the start of
the current RSV season, who meet one of the following conditions. Requests will be approved for a maximum of 5
doses, at a dosing interval of no fewer than 26 days between refills. Requests will be accepted beginning
November 12, 2018, prior to the season start date of November 26, 2018. Do not submit requests prior to November 12,
2018.
at least
For infants in the first year of life: (Check
one of the following AND indicate diagnosis code)
Any infant up to 12 months of age, born before 29 weeks 0 days gestation.
For infants born before 32 weeks 0 days gestation AND Chronic Lung Disease
(CLD) of prematurity with greater than 21% oxygen use for at least 28 days
ICD 10-CM
after birth
Code:
An infant with cystic fibrosis with clinical evidence of CLD AND/OR nutritional
ICD 10-CM
compromise
Code:
An infant with neuromuscular disease or pulmonary abnormality AND is unable
ICD 10-CM
to clear secretions from the upper airways
Code:
An infant who undergoes cardiac transplantation during the RSV season.
ICD 10-CM
Code:
Revision Date: 10/11/2018 
Infants with hemodynamically significant heart disease (acyanotic heart
ICD 10-CM
disease) defined as having one or more of the following:
Code:
Infants receiving medication to control congestive heart failure and will require cardiac surgical procedures;
Infants with moderate to severe pulmonary hypertension
both
An infant with cyanotic heart defects AND in consultation with a pediatric cardiologist AND
of the following:
Requirement of >21% oxygen for at least 28 days after birth
ICD 10-CM
Code:
Continues to require medical intervention (supplemental oxygen, chronic corticosteroid, or diuretic therapy)
An infant who will be profoundly immunocompromised during the RSV season
(solid organ or hematopoietic stem cell transplantation, receiving
ICD 10-CM
chemotherapy)
Code:
at least
For infants in the second year of life: (Check
one of the following AND indicate diagnosis code)
For infants born before 32 weeks 0 days gestation AND Chronic
Lung Disease (CLD) of prematurity AND Requirement of >21%
oxygen for at least 28 days after birth AND continue to require
medical intervention (supplemental oxygen, chronic corticosteroid,
ICD 10-CM
or diuretic therapy)
Code:
An infant who will be profoundly immunocompromised during the
RSV season (solid organ or hematopoietic stem cell
ICD 10-CM
transplantation, receiving chemotherapy)
Code:
Infants with manifestation of severe lung disease: (Choose one of the following AND add Diagnosis code)
Previous hospitalization for pulmonary exacerbation in the first
year of life or abnormalities of chest radiography or chest
ICD 10-CM
computed tomography that persist when stable OR
Code:
ICD 10-CM
Weight for length less than the 10th percentile.
Code:
An infant who undergoes cardiac transplantation during the RSV season.
Has the child received prior doses as an inpatient?
Yes
No
If yes, what date was the last dose received?
Prescriber signature (required). By signing, the prescriber confirms the criteria
Date
information above is accurate and verifiable in the member’s records.
Fax This Form to:
Magellan Prior Authorizations
Fax: 1-800-424-5881
Phone: 1-800-424-5725
Revision Date: 10/11/2018 
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