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2012-2013 Synagis Season

Respiratory Syncytial Virus

Enrollment Form

Network Health Prior Authorization Request

Network Health

Date: Needs by Date:

Fax to: 858-790-7100 or 877-501-1059

Ship to: Patient Office Other:

PATIENT INFORMATION (Complete the following or send patient demographic sheet)


Patient Name: Address: City, St., Zip: County: Home Phone: Last Four of SS #: Date of Birth: Parent/Guardian

Prescription Card:

Primary Insurance: Secondary Insurance: Name of Insurer:

Alternate Ph.:

Primary Language:


Prescriber's Name: State License #: DEA #: Group or Hospital: Address: City, State Zip: Phone: Contact Person:

ID#: ID#: ID#: BIN: Name of Insurer: Name of Insurer: PCN:


Fax: Phone:

Group: Phone: Phone:

INSURANCE INFORMATION (Please copy and attach the front and back of insurance and prescription drug card) Subscriber: Subscriber:

29-30 weeks of gestation (765.25) 31-32 weeks of gestation (765.26) 33-34 weeks of gestation (765.27) 35-36 weeks of gestation (765.28)

Diagnosis (Required):


37 weeks+ of gestation (765.29) Congenital Heart Disease (Specify ICD-9) Chronic Respiratory Disease arising in the perinatal period (CLD) (770.7) Congenital Abnormality of Respiratory System (748.3-748.4) Other:

< 24 weeks of gestation (765.21) 24 weeks of gestation (765.22) 25-26 weeks of gestation (765.23) 27-28 weeks of gestation (765.24)

Patient Evaluation: ·Patient's gestational age (Required): weeks days · Birth Weight: g/kg/lbs · Current Weight: g/kg/lbs · Date Recorded:

ICD-9: · Chronic Lung Pulmonary Disease** (CLD/BPD) and less than 24 months at start of RSV Season? Yes No ** Chronic Lung Disease is generally defined: For infants <32 weeks: Oxygen requirement at 36 weeks gestation age or at discharge. For infants > 32 weeks: Oxygen requirement at age 28 days or greater or at discharge. · Treatment for CLD within 6 months of onset of RSV season with: Oxygen Corticosteroids Start Date: Start Date: Last Date Received: Last Date Received: Yes ICD-9: Acyanotic Heart Disease Surgery to correct CHD Start Date: Yes No ICD-9: Yes No

Date surgery performed/planned:

Diuretics Bronchodilator No ICD-9:

Start Date: Start Date:

Last Date Received: Last Date Received: Yes No

· Diagnosis of congenital heart disease (CHD) and less than 24 months at start of season? · Patient has the following conditions: (Check one and provide ICD-9) Diagnosis of Moderate-Severe Pulmonary Hypertension Medications to control CHF (list): Cyanotic Heart Disease

· Is CHD hemodynamically significant at this time?

Last Date Received

· Significant congenital abnormality of the airway OR neuromuscular condition AND less than 12 months at start of season? Does condition cause compromised handling of secretions? · Prematurity: Gestational age of 28 weeks, 6 days AND less than 12 months at the start of season Gestational age of 29 weeks, 0 days ­ 31 weeks, 6 days AND less than 6 months at the start of season

Gestational age of 32 weeks, 0 days ­ 34 weeks, 6 days with the following risk factor(s) AND less than 3 months at the start of season: Name: · Siblings/children less than 5 years old living in the same household: " Multiple births younger than 1 year of age (twins, triplets) do not Name: qualify as fulfilling this risk factor" (AAP Redbook 2012) Child care attendance (defined as 2 or more unrelated children > 4 hours per week) started: · Multiple births? · NICU History: · List Allergies: (Please include NICU summary) · Previous injections? Yes Yes No Yes No · If yes, NICU name: No · If yes, dates: · Other medical history and/or Risk Factors: DOB: DOB: Date OR will start: Daycare name:

· Names of sibling RSV candidates (please submit separate enrollment form) · Was this season's first Synagis dose given in the NICU? · Expected date of first/next injection: Yes No · If yes, date(s):

Home Health Coordination:

· Specialty Pharmacy to coordinate home health nurse visit for injection? Yes No *Agency/Injection Clinic of choice:

MEDICATION Synagis (palivizumab) Epinephrine

(when required for home administration)


50 and/or 100mg vials 1:1000 amp


Inject 15mg/kg IM one time per month Other: _________________________________________ Inject 0.01mg/kg subcutaneously as directed for anaphylaxis


QS to achieve 15mg/kg dose


Prescriber has counseled parent/guardian on Synagis therapy and CVS Caremark may contact parent/guardian





PRODUCT SUBSTITUTION PERMITTED (Date) DISPENSE AS WRITTEN Note: The phone number on your fax-back referral confirmation letter will show the CVS Caremark pharmacy contact information for this patient. Please make note of it.

** American Academy of Pediatrics and The American College of Obstetricians and Gynecologists. Bronchopulmonary Dysplasia. Guidelines for Perinatal Care: 6 Edition. 2008; 273-276. IMPORTANT NOTICE: This facsimile transmission is intended to be delivered only to the named addressee and may contain material that is confidential, privilidged, proprietary or exempt from disclosure under applicable law. If it is received by anyone other than the named addressee, the receipent should immediately notify the sender at the address and telephone number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should such material be read or retained by anyone other the named addressee, except by express authority of the sender to the named addressee. RSV Synagis 082012


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