Resources to help appropriate patients get the treatment they need


Download these forms and tools to help appropriate patients start and continue treatment with SYNAGIS® (palivizumab).
 

 
 

Authorization for Transition of Care and Patient Consent Form

This document helps facilitate the transition from the hospital to the outpatient setting of an appropriate patient identified by a treating physician in the hospital as at high risk for RSV and potentially eligible for SYNAGIS.
 

 

 

Universal Referral Form

Fill out this form to provide appropriate patient, medical, and treatment information to SYNAGIS CONNECT or an appropriate specialty pharmacy.
 

 

Overview of SYNAGIS CONNECT

This program provided by Sobi for patients and their parents, guardians, and providers can help individuals understand their coverage and financial obligation for SYNAGIS and provide reimbursement support and resources.
 

 

 

SYNAGIS Patient Consent Form

To receive helpful information from SYNAGIS CONNECT, parents and guardians must offer their consent by filling out, signing, and submitting this form.
 

 

SYNAGIS Copay Program

Parents or guardians of eligible patients can use this brochure to learn how to reduce their out-of-pocket costs for each dose of SYNAGIS.
 

 

Specialty Pharmacy Network

This tool is useful whenever you need to call or fax an appropriate specialty pharmacy that provides SYNAGIS.
 

 

Coding Resource

This resource contains examples of helpful codes that may be used in the billing and reimbursement process for SYNAGIS.
 
IMPORTANT SAFETY INFORMATION
  • SYNAGIS is contraindicated in children who have had a previous significant hypersensitivity reaction to SYNAGIS
  • Cases of anaphylaxis and anaphylactic shock, including fatal cases, have been reported following initial exposure or re-exposure to SYNAGIS. Other acute hypersensitivity reactions, which may be severe, have also been reported on initial exposure or re-exposure to SYNAGIS. The relationship between these reactions and the development of antibodies to SYNAGIS is unknown. If a significant hypersensitivity reaction occurs with SYNAGIS, its use should be permanently discontinued. If a mild hypersensitivity reaction occurs, clinical judgment should be used regarding cautious readministration of SYNAGIS
  • As with any intramuscular injection, SYNAGIS should be given with caution to children with thrombocytopenia or any coagulation disorder
  • Palivizumab may interfere with immunological-based RSV diagnostic tests, such as some antigen detection-based assays
  • Adverse reactions occurring greater than or equal to 10% and at least 1% more frequently than placebo are fever and rash. In post-marketing reports, cases of severe thrombocytopenia (platelet count <50,000/microliter) and injection site reactions have been reported

INDICATION

SYNAGIS, 50 mg and 100 mg for injection, is indicated for the prevention of serious lower respiratory tract disease caused by respiratory syncytial virus (RSV) in pediatric patients:

  • with a history of premature birth (35 weeks gestational age) and who are 6 months of age or younger at the beginning of RSV season
  • with bronchopulmonary dysplasia (BPD) that required medical treatment within the previous 6 months and who are 24 months of age or younger at the beginning of RSV season
  • with hemodynamically significant congenital heart disease (CHD) and who are 24 months of age or younger at the beginning of RSV season

LIMITATIONS OF USE

The safety and efficacy of SYNAGIS have not been established for treatment of RSV disease.

DOSING

The recommended dose of SYNAGIS is 15 mg/kg of body weight given monthly by intramuscular injection. The first dose of SYNAGIS should be administered prior to commencement of the RSV season and the remaining doses should be administered monthly throughout the RSV season. Children who develop an RSV infection should continue to receive monthly doses throughout the RSV season.

The efficacy of SYNAGIS at doses less than 15 mg/kg, or of dosing less frequently than monthly throughout the RSV season, has not been established.

Please see accompanying full Prescribing Information for SYNAGIS, including Patient Information.

 

US-21252  Last Updated  6/18

 

 

Resources to help appropriate patients get the treatment they need


Download these forms and tools to help appropriate patients start and continue treatment with SYNAGIS® (palivizumab).
 

 
 

Authorization for Transition of Care and Patient Consent Form

This document helps facilitate the transition from the hospital to the outpatient setting of an appropriate patient identified by a treating physician in the hospital as at high risk for RSV and potentially eligible for SYNAGIS.
 

 

 

Universal Referral Form

Fill out this form to provide appropriate patient, medical, and treatment information to SYNAGIS CONNECT or an appropriate specialty pharmacy.
 

 

Overview of SYNAGIS CONNECT

This program provided by Sobi for patients and their parents, guardians, and providers can help individuals understand their coverage and financial obligation for SYNAGIS and provide reimbursement support and resources.
 

 

 

SYNAGIS Patient Consent Form

To receive helpful information from SYNAGIS CONNECT, parents and guardians must offer their consent by filling out, signing, and submitting this form.
 

 

SYNAGIS Copay Program

Parents or guardians of eligible patients can use this brochure to learn how to reduce their out-of-pocket costs for each dose of SYNAGIS.
 

 

Specialty Pharmacy Network

This tool is useful whenever you need to call or fax an appropriate specialty pharmacy that provides SYNAGIS.
 

 

Coding Resource

This resource contains examples of helpful codes that may be used in the billing and reimbursement process for SYNAGIS.
 
IMPORTANT SAFETY INFORMATION
  • SYNAGIS is contraindicated in children who have had a previous significant hypersensitivity reaction to SYNAGIS
  • Cases of anaphylaxis and anaphylactic shock, including fatal cases, have been reported following initial exposure or re-exposure to SYNAGIS. Other acute hypersensitivity reactions, which may be severe, have also been reported on initial exposure or re-exposure to SYNAGIS. The relationship between these reactions and the development of antibodies to SYNAGIS is unknown. If a significant hypersensitivity reaction occurs with SYNAGIS, its use should be permanently discontinued. If a mild hypersensitivity reaction occurs, clinical judgment should be used regarding cautious readministration of SYNAGIS
  • As with any intramuscular injection, SYNAGIS should be given with caution to children with thrombocytopenia or any coagulation disorder
  • Palivizumab may interfere with immunological-based RSV diagnostic tests, such as some antigen detection-based assays
  • Adverse reactions occurring greater than or equal to 10% and at least 1% more frequently than placebo are fever and rash. In post-marketing reports, cases of severe thrombocytopenia (platelet count <50,000/microliter) and injection site reactions have been reported

INDICATION

SYNAGIS, 50 mg and 100 mg for injection, is indicated for the prevention of serious lower respiratory tract disease caused by respiratory syncytial virus (RSV) in pediatric patients:

  • with a history of premature birth (35 weeks gestational age) and who are 6 months of age or younger at the beginning of RSV season
  • with bronchopulmonary dysplasia (BPD) that required medical treatment within the previous 6 months and who are 24 months of age or younger at the beginning of RSV season
  • with hemodynamically significant congenital heart disease (CHD) and who are 24 months of age or younger at the beginning of RSV season

LIMITATIONS OF USE

The safety and efficacy of SYNAGIS have not been established for treatment of RSV disease.

DOSING

The recommended dose of SYNAGIS is 15 mg/kg of body weight given monthly by intramuscular injection. The first dose of SYNAGIS should be administered prior to commencement of the RSV season and the remaining doses should be administered monthly throughout the RSV season. Children who develop an RSV infection should continue to receive monthly doses throughout the RSV season.

The efficacy of SYNAGIS at doses less than 15 mg/kg, or of dosing less frequently than monthly throughout the RSV season, has not been established.

Please see accompanying full Prescribing Information for SYNAGIS, including Patient Information.

 

US-21252  Last Updated  6/18