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Elizabeth M. Whitehorn, Director

Provider Notice issued 08/19/05

Prior Approval Form for Synagis Request

To:​ ​All Medical Providers
​Date: ​August 19, 2005
​Re: ​Prior Approval Form for Synagis Request

The Department of Healthcare and Family Services has developed a specialized prior approval form for Synagis requests. Pharmacies and physicians must use the new form to request Synagis prior approvals for the upcoming RSV season. The form is available on our web site at:

Under the Guidelines and Forms section. Completed forms may be faxed to 217-524-7264.nder the Guidelines and Forms section. Completed forms may be faxed to 217-524-7264.

 

For the 2005-2006 season, all strengths of Synagis will require prior approval. Providers are encouraged to submit prior approval requests for clinically appropriate children prior to October so the necessary prior approvals can be put in place prior to the beginning of the season.

 

If you have any questions regarding the form, please contact Pam Bunch at 217-524-7478.