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Synagis Prior Authorization Request Form (KY -MAP-82101, revised[removed]) ® st th Synagis authorizations will not be issued to allow for therapy dates before November 1 and after March 31
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Document Date: 2014-08-22 01:23:13

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File Size: 99,67 KB

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City

Medicaid / /

Facility

Pharmacy Department / Pharmacy Name /

/

Holiday

Commonwealth Day / /

MedicalCondition

bronchopulmonary dysplasia / Congestive Heart Failure / acyanotic congenital heart disease / Chronic Lung Disease / Cardiomyopathy / CHD / disease / Congenital abnormalities / Pulmonary Hypertension / /

MedicalTreatment

bypass surgery / /

Organization

Pharmacy Department / /

Product

Synagis / /

ProvinceOrState

Missouri / Kentucky / /

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