Synagis Prior Authorization Form Form

New Mexico Synagis Prior Authorization/Statement of Medical Necessity/Order Form CPT codes: (DRUG) 90378 / (PROCEDURE) 96372 NDC codes: SDV LIQ 50 mg/0.5ml 66658023001 / 100 mg/ml 66658023101 BCBS Western Sky Presbyterian Molina Other PA form valid: 2023-2024 Today’s date: Patient Name: Gender: DOB: Weight (current kg): Patient Address: Parent/Guardian Name: Primary Phone: Phone 2: Primary Insurance:
Insurance 2:
Patient SS#/Insurance ID: Member Insurance Group Number: Practitioner Name: Office Contact Name: Practitioner Address: Practitioner NPI: Practitioner Phone: Practitioner Fax: NICU graduate?: ☐ Yes ☐ No ☐ Unknown Synagis received last year? ☐ Yes ☐ No
Date of first dose:
Location of first dose: Gestational Age: **less than or equal to 28 weeks, 6 days OR other criteria met ICD-10 codes: (premature) P07.30 / (other) CRITERION: Circle the one criterion that best applies to this patient (one of the following must be circled and supporting documentation must be supplied): ICD-10 code: 1 <12 months old (as of Nov. 15) and with hemodynamically significant congenital heart disease (CHD) 2 (a) a. <12 months old (as of Nov. 15), < 32 weeks 0 days with chronic lung disease (CLD) of prematurity requiring oxygen of FiO2 >21% for >28 days after birth 2 (b) b. <24 months with chronic lung disease (CLD) and continues on supplemental oxygen, diuretic or corticosteroid 3 <24 months old (as of Nov. 15) and with Severe Immunodeficiency (specify type): 4 <12 months old (as of Nov. 15) with Severe Neuromuscular Disease with inability to clear secretions 5 <12 months old (as of Nov. 15) with congenital abnormality of the airway with inability to clear secretions 6 <12 months old (as of Nov. 15) and born at 28 weeks, 6 days gestation or less 7 <24 months old (as of Nov. 15) and will undergo cardiac transplantation during the RSV season INDIVIDUAL PRESCRIPTION ORDERS:

First/Next Injection Due Date: __ Delivery and Administration Location: ☐ Home Health Agency ☐ Clinic Home Health Agency/Clinic (if applicable): Phone:
Home Health Contact Name (if applicable): Home Health NPI:
☐ Synagis® (palivizumab) 50 mg and/or 100 mg vials (will dispense 50 mg/0.5 ml and/or 100mg/ml vial(s) based on prescribed dose) Sig: Inject 15 mg/kg IM every 28 days (dose to be calculated at the time of injection, based on patient’s current weight) Quantity: QS Refills:____ ☐ Refills through:___ To dispense the prescribed dose required at the time of injection, patient’s weight will be estimated as per standard operating procedure. ☐ Syringes (to withdraw) 1 ml 25G 5/8" ☐ Needles (to inject) Gauge: 25 Length: 5/8" Quantity QS (for both syringes and needles):____ ☐ Epinephrine 1:1000 amp (if required for home administration) Sig: Call 911 and MD then inject 0.01 mg/kg ____ mg SQ x 1; may repeat as needed for anaphylaxis as directed #3 amps Quantity: ___ Refills: ____ STATEMENT OF MEDICAL NECESSITY:
I hereby certify that the above services are medically necessary and are authorized by me. This patient is under my care and is in need of the services listed. Practitioner Signature: Date: ☐ APPROVED: Authorization # Authorization by: ☐ DENIED:

Synagis Submission Instructions Blue Cross Blue Shield NM

1. For Centennial: fax this completed form to Prime Therapeutics at 855-212-8110
2. Once PA has been approved, fax form to Accredo specialty pharmacy at 877-369-3447 (phone: 877-482-5927)
3. For commercial: fax this completed form to 866-589-8253 or submit online using Availity or call 800- 325-8334

4. Once PA has been approved, fax form to AllianceRx specialty pharmacy at 855-569-2511 (phone: 888- 282-5166) If problems arise, call Corinne Kenny, RN, care coordinator (Centennial & commercial), at 505-816-2893

   Medicaid

5. Fax this completed form to Medicaid FFS at 505-827-3185
6. Contact FFS Pharmacist at 505-819-1877
7. Once PA approval is issued by phone, fax prescription to a specialty pharmacy Specialty pharmacy: All FFS contracted specialty pharmacies
8. For home health prior authorization: Log in to Comagine Portal or call 866-962-2180 Molina
9. Fax this completed form to Molina Pharmacy Prior Authorization Department at 866-472-4578 (phone: 855-322-4078)
10. Once PA has been approved, fax form to Caremark specialty pharmacy at 800-323-2445 (phone: 800- 237-2767)
11. For home health: coordinate with specialty pharmacy and home health agency

Presbyterian

1. Fax this completed form to both fax numbers: 1) 800-724-6953 (Presbyterian Health Plan Pharmacy Services), and 2) 866-248-0801 (Presbyterian Specialty Care Pharmacy)
2. For prior authorization questions, call 505-923-5757 (select option 3 and follow prompts)
3. For specialty pharmacy questions, call 505-823-8800

4. For home health: coordinate with Presbyterian Specialty Care Pharmacy and the home health agency of your choice

   United Health Care NOTE: No PA is required for insurer

5. Download specialty pharmacy form by going to https://specialty.optumrx.com/forms and scrolling down to ‘RSV Regular Referral’ to open the pdf

6. Fax completed pharmacy form to Optum specialty pharmacy at 866-391-1890 (phone: 888-293- 9309; option 1)

   Western Sky Community Care

7. Fax this completed form to 833-395-5940
8. Once PA has been approved, fax form to AcariaHealth specialty pharmacy at 877-252-2444 (phone: 844- 796-2447) If problems arise, call our Provider Services Line at 1-844-738-5019 or send email to
   WSCC.Pharmacy@westernskycommunitycare.com NMPS contact for Synagis issues: Pawitta Kasemsap, MD, call: 505-620-8109 or email: pawitta.kasemsap@optum.com For help with patient financial assistance, PAs, additional assistance with care coordination or other issues, consider SOBI Synagis CONNECT at 1-833-796-2447 or https://synagis.com/synagis-connect.html
   Updated October 2022