Get the free Synagis® (palivizumab) Prior Authorization

This document is used to request prior authorization for Synagis (palivizumab) treatment, including patient's and physician's information, medication details, approval criteria, and necessary signatures.

How to fill out synagis palivizumab prior authorization

How to fill out Synagis® (palivizumab) Prior Authorization

1. Obtain the Synagis® Prior Authorization form from your insurance provider's website or office.
2. Fill in patient information including name, date of birth, and insurance details.
3. Provide a detailed medical history, including any previous respiratory illnesses or treatments.
4. Include the specific criteria for Synagis® administration, such as gestational age or congenital heart disease.
5. Attach any additional required documentation, like diagnostic test results or letters from the physician.
6. Review the completed form for accuracy and completeness.
7. Submit the form to the insurance provider via their preferred method (fax, mail, or online portal).
8. Follow up with the insurer to ensure the authorization has been processed and approved.

Who needs Synagis® (palivizumab) Prior Authorization?

1. Infants born prematurely (gestational age of 28 weeks or less).
2. Children under 2 years old with certain chronic lung conditions.
3. Infants with congenital heart disease.
4. Children with significant underlying medical conditions that increase their risk for RSV.

People Also Ask about

What makes you eligible for the RSV vaccine?

CDC recommends an RSV vaccine for all adults ages 75 years and older and for adults ages 50–74 years who are at increased risk of severe RSV. Risk factors that increase your risk for severe illness include: Chronic heart or lung disease. Weakened immune system.

Who qualifies for palivizumab?

In the first year of life, palivizumab prophylaxis is recommended for preterm infants with CLD of prematurity, defined as birth at <32 weeks, 0 days' gestation and a requirement for >21% oxygen for at least 28 days after birth.

What are the criteria for Synagis?

SYNAGIS gives babies who are born prematurely (at or before 35 weeks, and who are 6 months of age or less at the beginning of RSV season) the virus-blocking antibodies they lack, helping protect their vulnerable lungs from RSV.

What is a consideration for the administration of palivizumab Synagis?

Synagis is for intramuscular use only. As with any intramuscular injection, Synagis should be given with caution to children with thrombocytopenia or any coagulation disorder. Palivizumab may interfere with immunological-based RSV diagnostic tests such as some antigen detection-based assays.

Who is eligible for palivizumab?

In the first year of life, palivizumab prophylaxis is recommended for infants born before 29 weeks, 0 days' gestation. Palivizumab prophylaxis is not recommended for otherwise healthy infants born at or after 29 weeks, 0 days' gestation.

How much does palivizumab Synagis cost?

The cost for Synagis (100 mg/mL) intramuscular solution is around $1,910 for a supply of 0.5 milliliters, depending on the pharmacy you visit.

Who is entitled to an RSV injection?

Who should have the RSV vaccine. The RSV vaccine is recommended if: you're pregnant – the vaccine is recommended during every pregnancy (from 28 weeks onwards) to help protect your baby after they're born. you're aged 75 to 79.

Who is a candidate for palivizumab?

Palivizumab should only be considered for infants most vulnerable to severe RSV illness with a high likelihood of hospitalization, particularly in the first 6 months of life.

For pdfFiller’s FAQs

What is Synagis® (palivizumab) Prior Authorization?

Synagis® (palivizumab) Prior Authorization is a process required by some health insurance plans to determine if a patient is eligible to receive the medication Synagis, which is used for the prevention of respiratory syncytial virus (RSV) in high-risk infants and young children.

Who is required to file Synagis® (palivizumab) Prior Authorization?

Typically, healthcare providers or prescribers, such as pediatricians or specialists managing the care of high-risk infants, are required to file the Synagis® (palivizumab) Prior Authorization on behalf of their patients.

How to fill out Synagis® (palivizumab) Prior Authorization?

To fill out the Synagis® (palivizumab) Prior Authorization, providers must complete a designated form from the insurance company, providing necessary patient information, clinical history, and justification for the use of the medication based on the established criteria.

What is the purpose of Synagis® (palivizumab) Prior Authorization?

The purpose of Synagis® (palivizumab) Prior Authorization is to ensure that the medication is prescribed to patients who meet specific criteria, ultimately to manage costs and ensure that the therapy is used appropriately, reducing the risk of unnecessary treatments.

What information must be reported on Synagis® (palivizumab) Prior Authorization?

The information that must be reported includes patient demographics, diagnosis codes, medical history, the rationale for use, previous treatments, and any relevant laboratory results or risk factors that justify the need for Synagis®.