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Synagis® 2021-2022 Prior Authorization form – updated

The updated 2021-2022 prior authorization form for Synagis® has been posted to the Prior Authorization page.  DOM will begin accepting prior authorization requests on October 11, 2021 and allow providers to begin administering doses for dates of service beginning November 1, 2021. For more information, please visit the 2021-2022 Synagis PA packet posted on the DOM Prior Authorization page.

Please note: the 2020-2021 RSV-Synagis® PA form will also remain posted through 10/31/21 for case-by-case dosing consideration outside of the typical RSV season.