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SYN.23 Form # 30120 R: 10.13 State of Maine Department of Health & Human Services MaineCare/MEDEL Prior Authorization Form
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Document Date: 2013-10-25 11:54:56

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File Size: 41,00 KB

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MedicalCondition

either severe neuromuscular disease / chronic lung disease / hemodynamically significant congenital heart disease / severe pulmonary hypertension Cyanotic heart disease / congenital abnormalities / ie bronchopulmonary dysplasia / /

Organization

American Academy of Pediatrics / Department of Health / Committee on Infectious Diseases / MaineCare / /

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Product

SYNAGIS / /

URL

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