Synagis (Palivizumab) Prior Authorization Form

The Synagis Prior Authorization Form is designed for healthcare providers to request coverage for palivizumab, a medication used to prevent respiratory syncytial virus (RSV) in at-risk infants. The form requires specific patient information including diagnosis, gestational age, and treatments. It details the required criteria for approval, including various diagnoses related to the infant’s age and medical history. Additionally, providers must complete and submit the form to ensure timely processing for eligible patients. For further inquiries, the form includes a contact for Navitus Customer Care.