Synagis Prior Authorization Form

MedStar Family Choice follows the American Academy of Pediatrics 2014 guidelines for Synagis (palivizumab) administration (see link below).

Requests for Synagis (palivizumab) require a completed 2017-2018 Synagis® Seasonal Respiratory Syncytial Virus Enrollment Form (see link below). Please fax completed forms to Caremark Specialty Pharmacy at 877-552-2907 and a second copy to MedStar Family Choice at 410-933-2274.

If you have questions for MedStar Family Choice, call 410-933-2200, option 1.

View the American Academy of Pediatrics 2014 Synagis (palivizumab) Guidelines.

Information current as of: