Get the free PRIOR AUTHORIZATION: Synagis® (palivizumab)

This document is a Prior Authorization form for the RSV prophylaxis medication Synagis® (palivizumab), detailing patient information, physician details, prescription information, and criteria for

How to fill out prior authorization synagis palivizumab

How to fill out PRIOR AUTHORIZATION: Synagis® (palivizumab)

1. Obtain the PRIOR AUTHORIZATION form from your healthcare provider or insurance company.
2. Fill out the patient's information, including name, date of birth, and insurance details.
3. Indicate the medical necessity of Synagis® (palivizumab) by providing relevant clinical information, such as the patient's diagnosis and risk factors.
4. Provide details about previous treatments, if any, and the patient's medical history related to respiratory complications.
5. Include dosing information, specifying the recommended dosage and duration of treatment.
6. Review the form for accuracy and completeness before submission.
7. Submit the completed PRIOR AUTHORIZATION form to the insurance company via fax, mail, or their online portal as required.
8. Follow up with the insurance company to ensure that the PRIOR AUTHORIZATION is processed in a timely manner.

Who needs PRIOR AUTHORIZATION: Synagis® (palivizumab)?

1. Infants and young children at high risk for respiratory syncytial virus (RSV) infection.
2. Individuals with certain chronic lung diseases or those who were born prematurely.
3. Patients with congenital heart disease who may have an increased risk for severe RSV disease.

People Also Ask about

What is a consideration for the administration of palivizumab SYNAGIS?

SYNAGIS® (palivizumab) should be administered in a dose of 15 mg/kg via IM injection using aseptic technique, preferably in the anterolateral aspect of the thigh. The gluteal muscle should not be used routinely as an injection site because of the risk of damage to the sciatic nerve.

Is SYNAGIS still recommended?

Synagis is only approved for certain infants and young children who are especially vulnerable to severe RSV. The American Academy of Pediatrics (AAP) recommends Synagis for the following children in their first year of life: Premature infants who were born before 29 weeks gestation.

How do you qualify 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.

Is palivizumab used for RSV prophylaxis?

RSV Prophylaxis Taking palivizumab prophylactically decreases the number of RSV infections, decreases wheezing, and may decrease the rate of hospitalization attributed to RSV. There are few negative side effects reported.

How much does Synagis cost in the US?

SYNAGIS® (palivizumab) may be covered under a patient's pharmacy or medical benefit. Sometimes SYNAGIS is covered under both benefits, or by more than 1 plan, depending on the patient's insurance. To ensure timely approval for SYNAGIS, collect all prescription and medical benefit information for appropriate patients.

How much does palivizumab cost for RSV?

Outcomes Measure Incremental cost (2010 US dollars) per hospitalization for RSV infection avoided. Results The mean cost of palivizumab per dose ranged from $1661 for infants younger than 6 months of age to $2584 for children in their second year of life.

Who qualifies for RSV vaccine?

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. Quoted prices are for cash-paying customers and are not valid with insurance plans.

Who qualifies 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.

For pdfFiller’s FAQs

What is PRIOR AUTHORIZATION: Synagis® (palivizumab)?

PRIOR AUTHORIZATION for Synagis® (palivizumab) is a process used by health insurance providers to determine if the treatment is medically necessary before covering the costs. It is typically required for high-risk infants and children to prevent severe respiratory synctial virus (RSV) infections.

Who is required to file PRIOR AUTHORIZATION: Synagis® (palivizumab)?

Healthcare providers, such as pediatricians or specialists who prescribe Synagis® (palivizumab), are required to file the PRIOR AUTHORIZATION. Additionally, the patient's insurance company may specify other necessary information.

How to fill out PRIOR AUTHORIZATION: Synagis® (palivizumab)?

To fill out the PRIOR AUTHORIZATION form for Synagis®, the health care provider needs to include patient information, clinical history, and rationale for treatment, as well as relevant medical codes and insurance details as required by the specific insurance plan.

What is the purpose of PRIOR AUTHORIZATION: Synagis® (palivizumab)?

The purpose of PRIOR AUTHORIZATION for Synagis® is to ensure that the prescribed treatment is appropriate for the patient's condition, to manage healthcare costs, and to prevent unnecessary treatments in patients who are not at high risk for severe RSV.

What information must be reported on PRIOR AUTHORIZATION: Synagis® (palivizumab)?

The information that must be reported includes patient demographics, medical history, specifics about RSV risk factors, proposed treatment regimen, and any prior treatments and outcomes, as well as supporting documentation from medical professionals.