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Synagis® 2022 off-season prior authorization form

Effective July 29, 2022, prior authorization requests for Synagis will be considered for approval of 2 doses at least 30 days apart. If necessary, an additional 2 doses may be approved at a later date should elevated community RSV prevalence continue. DOM will continue to monitor RSV status in consultation with pediatricians throughout the state. The off-season form can be found on the DOM Prior Authorization page.

As fall approaches, DOM will be posting an updated prior authorization form for use during the upcoming typical fall-to-spring RSV season.