Synagis Prior Authorization Form

This PDF contains the Synagis Prior Authorization Form, intended for use by prescribers seeking authorization for the administration of palivizumab to high-risk infants. It details required criteria, including specific diagnoses and ICD codes that must be met to qualify for treatment. The document is crucial for ensuring timely processing and approval for up to five monthly doses during the RSV season. Additional instructions for submission and contact details for inquiries are also provided. The form is specifically designed to assist healthcare providers in managing RSV prophylaxis effectively.