Submit online or fax completed
form to: 855-207-0250
For questions regarding this prior
authorization, call
• Synagis season will be October 19
th
through April 21
st
• Providers will choose when to start dosing Synagis based on prevalence of RSV in the community
• Clinicians may administer up to a maximum of 5 monthly doses during the RSV season.
• Qualifying infants born during the RSV season may require fewer doses.
TO BE COMPLETED BY PRESCRIBER
Recipient Medicaid ID Number
Is this request for dose from the current RSV season, last RSV season, or both (please select one)?
□ Previous Year’s RSV season □ Current Year’s RSV Season □ Both
Diagnosis (qualification for Synagis)
___ Prematurity
<29 weeks, 0 days gestational age – Synagis allowed if younger than 12 months of age at start of RSV season (max of 5 doses)
Gestational Age (e.g. 28 weeks, 4 days)
Weeks ________________________ Days ________________________
___ Chronic Lung Disease of Prematurity (CLD) – Child ≤12 months old with gestational age <32 weeks, 0 days and requires
supplemental oxygen >21% for at least the first 28 days after birth.
___ Chronic Lung Disease of Prematurity (CLD) – Child ≤24 months old with gestational age <32 weeks, 0 days and requires
supplemental oxygen >21% for at least the first 28 days after birth and continues to receive medical support within six months before
the start of RSV season.
___ Supplemental Oxygen
___ Diuretic
___ Chronic corticosteroid therapy
___ Congenital Heart Disease (CHD)
Child ≤12 months old with hemodynamically significant cyanotic or acyanotic CHD
Medical Therapy Required ___________________________________________________
*children less than 24 months who undergo cardiac transplantation during RSV season may be considered for prophylaxis.
___ Neuromuscular disease (may be considered for prophylaxis during the first year of life)
___ Pulmonary abnormalities (may be considered for prophylaxis during the first year of life)
___ Profoundly Immunocompromised children (children <24 months of age may be considered for prophylaxis during the RSV season)
*Accessed online at pediatrics.aappublications.org
Prior Authorization Vendor for ND Medicaid
