Form FA-65 Synagis Prior Authorization - Nevada

Form FA-65 or the "Synagis Prior Authorization" is a form issued by the Nevada Department of Health and Human Services.

The form was last revised in October 25, 2018 and is available for digital filing. Download an up-to-date Form FA-65 in PDF-format down below or look it up on the Nevada Department of Health and Human Services Forms website.

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Prior Authorization Request
Nevada Medicaid – OptumRx
Synagis
®
Prior Authorization
Submit fax request to: 855-455-3303
®
Purpose: For a prescribing physician to request Synagis
for the Nevada Respiratory Syncytial Virus (RSV) season November
1, 2018, through March 31, 2019. Synagis
authorization will not be issued for therapy dates in the 2018 season after March 31,
®
2019. Questions: If you have questions, call the OptumRx Call Center for Nevada Medicaid at 855-455-3311.
DATE OF REQUEST:
RECIPIENT INFORMATION
Last name, First name, Middle initial:
Date of birth:
Recipient ID:
Gender:
Male
Female
Phone:
Gestational age: ______ Weeks ______ Days *Both weeks and days are required.
Current weight:______________
Date on which current weight was recorded:
If Hospice, list Hospice diagnosis:
PROVIDER INFORMATION
(This request must be submitted by the prescribing physician.)
Name:
NPI:
Specialty:
Phone:
Fax (required):
Person to contact regarding this request:
COVERAGE CRITERIA
Please check the applicable boxes to indicate each item as true for the recipient:
Child is <12 months of age at the onset of RSV season on November 1 (born after 11/1/17).
Child is <24 months of age at the onset of RSV season on November 1 (born after 11/1/16).
Child has a diagnosis of chronic lung disease of prematurity (formerly called bronchopulmonary dysplasia).
Child required > 21% oxygen for at least the first 28 days of life.
Child has required medical treatment for chronic lung disease of prematurity in the preceding six months (only
required if child is ≥ 12 months of age). Please check all that apply and document administration dates:
Oxygen
Most recent date administered: __________________________
Corticosteroids
Most recent date administered: __________________________
Bronchodilators
Most recent date administered: __________________________
Diuretics
Most recent date administered: __________________________
Child has hemodynamically significant cyanotic or acyanotic congenital heart disease (CHD)
Please check all that apply and document medications received or date of surgeries:
Congestive heart failure/cardiomyopathy; Medications: _____________________________________
Moderate to severe pulmonary hypertension; Medications:____________________________________
Cyanotic heart disease; Medications: ___________________________________________________
Cardiopulmonary bypass surgery; Date: _________________________________________________
Other diagnosis; Document:__________________________Medications:_________ ______________
The child has congenital abnormalities of the airways. Document:_________________________________
The child has a neuromuscular disease that impairs the ability to clear secretions from the upper airway.
Document diagnosis:__________________________________________________________________
Child has had or will have a cardiac transplant; Date of transplant:_________________________________
Child is severely immunocompromised during the RSV season; Document:______________________________
Child has cystic fibrosis: (please check all that apply):
Child has clinical evidence of chronic lung disease.
Child has clinical evidence of nutritional compromise.
For children with cystic fibrosis ≥ 12 months of age:
Weight-for-length less than 10th percentile; Length:_______________
Child has had previous hospitalization for pulmonary exacerbation in the first year of life.
Child has abnormalities on chest radiography or chest computed tomography that persists when stable.
PROVIDER CERTIFICATION –
Prescriber’s signature and date are required.
.
I hereby certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by Nevada Medicaid
Prescriber’s Signature:
Date:
This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions, coordination of
benefits and other terms and conditions set forth by the benefit program. The information on this form and on accompanying attachments is privileged and confidential and is
only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the employee or agent responsible to deliver it to the
intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If this communication is received in
error, the reader shall notify sender immediately and destroy all information received.
FA-65 Updated 10/25/2018 pv10/03/2017
Page 1 of 1
Prior Authorization Request
Nevada Medicaid – OptumRx
Synagis
®
Prior Authorization
Submit fax request to: 855-455-3303
®
Purpose: For a prescribing physician to request Synagis
for the Nevada Respiratory Syncytial Virus (RSV) season November
1, 2018, through March 31, 2019. Synagis
authorization will not be issued for therapy dates in the 2018 season after March 31,
®
2019. Questions: If you have questions, call the OptumRx Call Center for Nevada Medicaid at 855-455-3311.
DATE OF REQUEST:
RECIPIENT INFORMATION
Last name, First name, Middle initial:
Date of birth:
Recipient ID:
Gender:
Male
Female
Phone:
Gestational age: ______ Weeks ______ Days *Both weeks and days are required.
Current weight:______________
Date on which current weight was recorded:
If Hospice, list Hospice diagnosis:
PROVIDER INFORMATION
(This request must be submitted by the prescribing physician.)
Name:
NPI:
Specialty:
Phone:
Fax (required):
Person to contact regarding this request:
COVERAGE CRITERIA
Please check the applicable boxes to indicate each item as true for the recipient:
Child is <12 months of age at the onset of RSV season on November 1 (born after 11/1/17).
Child is <24 months of age at the onset of RSV season on November 1 (born after 11/1/16).
Child has a diagnosis of chronic lung disease of prematurity (formerly called bronchopulmonary dysplasia).
Child required > 21% oxygen for at least the first 28 days of life.
Child has required medical treatment for chronic lung disease of prematurity in the preceding six months (only
required if child is ≥ 12 months of age). Please check all that apply and document administration dates:
Oxygen
Most recent date administered: __________________________
Corticosteroids
Most recent date administered: __________________________
Bronchodilators
Most recent date administered: __________________________
Diuretics
Most recent date administered: __________________________
Child has hemodynamically significant cyanotic or acyanotic congenital heart disease (CHD)
Please check all that apply and document medications received or date of surgeries:
Congestive heart failure/cardiomyopathy; Medications: _____________________________________
Moderate to severe pulmonary hypertension; Medications:____________________________________
Cyanotic heart disease; Medications: ___________________________________________________
Cardiopulmonary bypass surgery; Date: _________________________________________________
Other diagnosis; Document:__________________________Medications:_________ ______________
The child has congenital abnormalities of the airways. Document:_________________________________
The child has a neuromuscular disease that impairs the ability to clear secretions from the upper airway.
Document diagnosis:__________________________________________________________________
Child has had or will have a cardiac transplant; Date of transplant:_________________________________
Child is severely immunocompromised during the RSV season; Document:______________________________
Child has cystic fibrosis: (please check all that apply):
Child has clinical evidence of chronic lung disease.
Child has clinical evidence of nutritional compromise.
For children with cystic fibrosis ≥ 12 months of age:
Weight-for-length less than 10th percentile; Length:_______________
Child has had previous hospitalization for pulmonary exacerbation in the first year of life.
Child has abnormalities on chest radiography or chest computed tomography that persists when stable.
PROVIDER CERTIFICATION –
Prescriber’s signature and date are required.
.
I hereby certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by Nevada Medicaid
Prescriber’s Signature:
Date:
This authorization request is not a guarantee of payment. Payment is contingent upon eligibility, available benefits, contractual terms, limitations, exclusions, coordination of
benefits and other terms and conditions set forth by the benefit program. The information on this form and on accompanying attachments is privileged and confidential and is
only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the employee or agent responsible to deliver it to the
intended recipient, the reader is hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If this communication is received in
error, the reader shall notify sender immediately and destroy all information received.
FA-65 Updated 10/25/2018 pv10/03/2017
Page 1 of 1

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