Infina Connect Document For Safety

Synagis Resources

Resource Links

Procedures for PA Request for Synagis for RSV Season 2018-2019 (PDF) NC Medicaid Prior Approval Criteria for Palivizumab, September 4, 2018 (PDF) NC Legislative Language Requiring Electronic Prior Authorization Requests (see 10.31.(b) number (6)) Information about EPSDT Non-Covered State Medicaid Plan Services Request Form for Recipients Under 21 Years Old

Please fax the completed form to 919-715-1255.


The clinical criteria utilized in this policy are consistent with guidance published by the American Academy of Pediatrics (AAP): 2018-2021 Report of the Committee on Infectious Diseases, 30th Edition.