 Pennsylvania Pharmacy  Tennessee Pharmacy
Synagis® (palivizumab) Statement of Medical Necessity
Ph. 800-906-7798
Synagis Ph. 855-229-0952
For additional information, please contact your
Fax 877-381-3806
Ph. 800-906-7798 x 129
account manager or visit acropharmacy.com.
Fax 844-612-9057
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PATIENT INFORMATION:
PRESCRIBER INFORMATION:
PATIENT NAME: ______________________________________________ SEX: M F
PRESCRIBER’S NAME: __________________________________________________
ALLERGIES: _____________________________ WEIGHT: ______lbs. /kg HEIGHT: ______ MD LICENSE #: ____________________ MD NPI#: ___________________________
DATE OF BIRTH: _____________ SOCIAL SECURITY #: ____________________________
CLINIC NAME: ____________________________SPECIALTY:___________________
ADDRESS: _________________________________________________ APT#__________
CONTACT NAME: _____________________________________________________
CITY: ______________________________________ STATE: ______ ZIP: ____________
ADDRESS: _________________________________ SUITE #: ___________________
HOME PHONE: ________________________ WORK PHONE: ______________________
CITY: _________________________________ STATE: ________ ZIP: ____________
CELL PHONE: ________________________ EMAIL: ______________________________
PHONE: __________________________ FAX: _______________________________
CAREGIVER NAME: _________________________ PHONE: ________________________
EMAIL: ______________________________________________________________
INSURANCE INFORMATION:
Please include copies of the patient’s insurance/drug benefit cards (front and back) to expedite benefit clearance.
PRIMARY INSURANCE: ______________________________________ POLICY #: _________________________________ GROUP #: __________________________________
POLICY HOLDER: _________________________________________ EMPLOYER: __________________________ INSURANCE PHONE #: _______________________________
CLINICAL INFORMATION: To ensure prompt processing please complete all of the questions.
Patient’s Gestational Age: _______ weeks _______ days Birth Weight: ________ g / kg / lbs Current Weight: ________ g / kg / lbs Date Recorded: __________
Please Document All Diagnoses and Document to the
Highest Degree of ICD-10 Detail
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≤ 24 Weeks of Gestation (P07.21-P07.22)
25-26 Weeks of Gestation (P07.24-P07.25)
27-28 Weeks of Gestation (P07.26-P07.27)
29-30 Weeks of Gestation (P07.32-P07.33)
31-32 Weeks of Gestation (P07.34-P07.35)
33-34 Weeks of Gestation (P07.36-P07.37)
35 Weeks of Gestation (P07.38)
Other Respiratory Conditions of Fetus & Newborn – ICD-10: ____
Secondary Diagnosis (If Applicable): ___________
Breakthrough RSV Hospitalization
Additional Risk Factors:
 Child Care Attendance by the Infant Home or Facility
 Sibling(s) Younger than 5 Years of Age Living in the Same Household.
Medical Criteria (Please attach clinical documentation for all diagnoses below)
1.
Diagnosis of Chronic Lung Diseases (CLD) (ICD-10:P27.8)?  Yes  No
 Oxygen Concentration: ___________ Dates: ___________
 Supporting Clinical Documents are attached for Oxygen Use.
 Bronchodilator
 Corticosteroids
 Diuretics
___ / ___ /___
___ / ___ /___
___ / ___ /___
2.
Diagnosis of Hemodynamically Significant Congenital Heart Disease?  Yes  No
IDC-10: ___________
Patient has the following conditions:
 Diagnosis of Moderate-Severe Pulmonary Hypertension
 Cyanotic Heart Disease
 Acyantoic Heart Disease
 Medications for CHF (list): _______________ Last Date Received: ___ / ___ /___
Recent Surgical Procedure Requiring Cardiopulmonary Bypass
 Yes  No
If yes, an additional post-operative dose of palivizumab may be medically necessary.
NICU History
 Yes  No NICU Name: ________________________________
Please Attach the NICU Discharge Summary
Was there a NICU Dose Administered?  Yes  No
Dates: ____ / ____ /____
3.
Diagnosis of Cystic Fibrosis with one of the following risk factors?  Yes  No
IDC-10: ___________
 Clinical Evidence of CLD
 Nutritional Compromise
 Manifestations of sever lung disease (previous hospitalization for pulmonary
exacerbation in the first year of life or abnormalities on chest radiography or chest
computed tomography that persist when stable)
 Weight for length less than 10th percentile
4.
5.
Diagnosis of profoundly immunocompromised? Reason: _______________________
Diagnosis of Congenital Abnormalities of the airway and 12 months of age or less?
 Yes  No IDC-10: ___________
Neuromuscular condition that compromises handling of respiratory secretions and
12 months of age or less?
 Yes  No IDC-10: ___________
Expected Date of First/Next Injection: ___ / ____ / ____
Previous Injections?  Yes  No Dates: ____ / ____ /____
Rx
Synagis (palivizumab) 50 mg and/or 100 mg Vials
Sig: Inject 15 mg/kg IM One Time per Month
Dispense Quantity: QS Refills Through: ____ / ____ /____
Other:
 Parent/Caregivers have been contacted and we have been
granted permission to contact.
6.
Agency Nurse to Visit Home for Injection?  Yes  No
Prescribers Signature: ______________________________________ Date: ____________
Dispense as Written
Deliver Medication to:
 Patient’s Home
________________________________________ Date: __________________
Substitution Permissible
 Physician’s Office  Other: ___________________________ Requested Date of Delivery: ________________________
Thank you for using Acro Pharmaceutical Services!
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Prescriber’s Signature