Health Net
Synagis (palivizumab)
Drugs for Infections : Drugs for Viral Infections
  • Prior Authorization: Respiratory Syncytial Virus (RSV):
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Age Requirement: < 2
    Reauthorization Required: Yes

  • Respiratory Syncytial Virus (RSV):
    Age Requirement: < 2
    Specialist Required: Yes
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Specialist Type(s): Pediatric Cardiologist
    Reauthorization Required: Yes
    Duration of Reauthorization: Unspecified

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