Patient Name     (Last)                  (First)               (MI)

WV Medicaid ID #:

Date of Birth

Physician DEA Number

Phone #

FAX #

FAX, Phone, or Mail Completed Form To:

Physician Name  (Last)             (First)                  (MI)

Rational Drug Therapy Program

Physician Street Address: 

West Virginia University

School of Pharmacy

Physician City Address              State                    Zip

P.O. Box 9511 HSCN

Pharmacy NABP Number

Phone #

FAX #

Morgantown, WV  26506-9511

Pharmacy Name:

Pharmacy Street Address

FAX # 1-800-531-7787

Pharmacy City Address                State                  Zip

Phone #  1-800-847-3859

Medication Name:

Palivizumab (Synagis^R)

Monthly Dose

Directions

State Chronic Pulmonary Diagnosis or Gestational Risk Factor(s):

Actual Gestational Age ___________ weeks

Current Age (Must be <24 months) ___________ months

Palivizumab Prior Approval Criteria Guidelines

Gestational Age/Disease State

Maximum Age of  Patient to Start Therapy

Chronic Lung Disease, any Gestational Age

24 months

< 28 weeks Gestational Age

12 months

28-32 weeks Gestational Age

6 months

32-36 weeks Gestational Age

3 months (6 months with added risk factors-MUST DOCUMENT ABOVE)

(Risk Factors Include: School age siblings, crowding in the home, day-care attendance, exposure to tobacco smoke in the home, and multiple births)

Maximum allowed: Six (6) doses during the RSV Season of October 15^th thru April 30^th

For Rational Drug Therapy Program Use Only

Reason for Denial of Request or Specific Notes:

Approval/Denial Status

Authorization ID #

Date of Request

Therapeutic Class/Generic Code

Rev: 12/06/01