Synagis Form Submission:
You can now fill out and submit your Synagis Prior Authorization requests online.
Submit Request Online
Please select the desired link from the list below.
Title | Categories | Update Date | Download |
---|---|---|---|
ACE-I ARB Renin Inhibitor PA Form 1 file(s) 12 downloads |
ND | November 16, 2016 | Download |
Acne PA form 1 file(s) 9 downloads |
ND | November 16, 2016 | Download |
Actinic Keratosis PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Akynzeo 1 file(s) 11 downloads |
ND | November 15, 2016 | Download |
Akynzeo PA Form 1 file(s) 9 downloads |
ND | November 16, 2016 | Download |
Albuterol Levalbuterol rescue inhalers PA form 1 file(s) 8 downloads |
ND | November 16, 2016 | Download |
Allergenic Extracts – Oral PA form 1 file(s) 9 downloads |
ND | November 16, 2016 | Download |
Alteplase PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Ampyra PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Amrix PA Form 1 file(s) 9 downloads |
ND | November 16, 2016 | Download |
Anesthetics – Topical PA form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Anticoagulants – Injectable PA form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Anticoagulants – Oral PA form 1 file(s) 11 downloads |
ND | November 16, 2016 | Download |
Antihemophilic Factor Products PA Form 1 file(s) 8 downloads |
ND | November 16, 2016 | Download |
Antihistamine PA Form 1 file(s) 9 downloads |
ND | November 16, 2016 | Download |
Antimalarial Agents PA form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Antipsoriatic – Topical PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Aubagio PA Form 1 file(s) 8 downloads |
ND | November 16, 2016 | Download |
Bowel Prep Agents PA Form 1 file(s) 9 downloads |
ND | November 16, 2016 | Download |
Brisdelle PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Carisoprodol PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Cialis for BPH PA Form 1 file(s) 8 downloads |
ND | November 16, 2016 | Download |
Combination Products PA Form 1 file(s) 8 downloads |
ND | November 16, 2016 | Download |
Copaxone 40 PA Form 1 file(s) 10 downloads |
ND | November 16, 2016 | Download |
COPD Agents PA Form 1 file(s) 8 downloads |
ND | November 16, 2016 | Download |
Corticosteroid/LABA Combination Inhaled Agents PA form 1 file(s) 10 downloads |
ND | November 16, 2016 | Download |
Cystic Fibrosis Anti-Infectives PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Cytokine Modulators PA Form 1 file(s) 11 downloads |
ND | November 16, 2016 | Download |
Daklinza Form 1 file(s) 9 downloads |
ND | November 16, 2016 | Download |
Dexpak/Zemapak PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Diabetic Test Strips PA Form 1 file(s) 10 downloads |
ND | November 16, 2016 | Download |
Diclegis PA Form 1 file(s) 8 downloads |
ND | November 16, 2016 | Download |
Dificid PA Form 1 file(s) 10 downloads |
ND | November 16, 2016 | Download |
Digestive Enzymes PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Dispense as Written PA Form 1 file(s) 11 downloads |
ND | November 16, 2016 | Download |
Edecrin PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Elaprase PA Form 1 file(s) 9 downloads |
ND | November 16, 2016 | Download |
Epclusa PA Form 1 file(s) 8 downloads |
ND | November 16, 2016 | Download |
Epinephrine Auto Injectors PA Form 1 file(s) 9 downloads |
ND | November 16, 2016 | Download |
FDA MedWatch Form 3500 1 file(s) 9 downloads |
ND | May 15, 2017 | Download |
Fulyzaq PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Generic Not Preferred Form 1 file(s) 20 downloads |
ND | November 16, 2016 | Download |
Genitourinary Smooth Muscle Relaxants PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Gilenya PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
GLP-1 Receptor Agonists PA Form 1 file(s) 10 downloads |
ND | November 16, 2016 | Download |
Glumetza PA Form 1 file(s) 5 downloads |
ND | November 16, 2016 | Download |
Gralise PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Growth Hormone PA Form 1 file(s) 9 downloads |
ND | November 16, 2016 | Download |
Harvoni PA Form 1 file(s) 8 downloads |
ND | November 16, 2016 | Download |
Hemangeol PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Hepatitis C Patient Consent Form 1 file(s) 14 downloads |
ND | November 16, 2016 | Download |
Hereditary Angioedema Agents 1 file(s) 8 downloads |
ND | November 16, 2016 | Download |
Horizant PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
IBS/OIC Agents PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Idiopathic Pulmonary Fibrosis Agents PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Immune Globulins PA Form 1 file(s) 6 downloads |
ND | May 17, 2017 | Download |
Insulin PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Interferons – Hepatitis C PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Interferons – Multiple Sclerosis PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Interleukin-5 Antagonist PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Kalydeco PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Kapvay PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Ketek PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Ketoconazole – Topical PA form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Kits PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Kuvan PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Lemtrada PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Lice Medications PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Lorzone PA Form 1 file(s) 10 downloads |
ND | November 16, 2016 | Download |
Luzu PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Marinol PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Meds greater than 3,000 PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Metozolv PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Mifeprex PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Moxatag PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Naloxone Rescue Medications PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Naltrexone – Oral PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Narcotic/APAP PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Nasal Steroids PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Nexiclon PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Nitroglycerin Lingual Spray 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Northera PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Noxafil PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
NSAID/COX-II PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Nuedexta PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Nuvessa PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
ODT Preparations PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Olysio PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Onmel PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Onychomycosis Agents PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Ophthalmic Anti-Infectives PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Ophthalmic Antihistamines PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Opioid Analgesic – Long Acting PA Form 1 file(s) 8 downloads |
ND | November 16, 2016 | Download |
Opioid Analgesic – Short Acting PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Opioid Dependence PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Oravig PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Otezla PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Otic Anti-Infectives PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Out of State Pharmacy PA Form 1 file(s) 10 downloads |
ND | November 16, 2016 | Download |
PCSK9 Inhibitors PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Phosphate Binders PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Promacta PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Proton Pump Inhibitors PA Form 1 file(s) 10 downloads |
ND | November 16, 2016 | Download |
Provigil/Nuvigil PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Pulmonary Arterial Hyptertension PA Form 1 file(s) 8 downloads |
ND | November 16, 2016 | Download |
Pulmozyme PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Rasuvo and Otrexup PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Rayos PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Ribapak PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Rosacea PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Sancuso PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Sedative Hypnotic PA Form 1 file(s) 8 downloads |
ND | November 16, 2016 | Download |
SGLT2 Inhibitors PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Sovaldi PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Statins PA Forms 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Steroid Inhalers PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Tecfidera PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Technivie PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Testosterone – Topical PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Tirosint PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Tobacco Cessation PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Triptans PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Tysabri PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Ulcer Anti-Infectives PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Ulcerative Colitis PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Uloric PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Vanos PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Varubi PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Vecamyl PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Viekira PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Vusion PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Xeljanz PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Xenical PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Xifaxan PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Xolair PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |
Xyrem PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Zanaflex Capsule PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Zepatier PA Form 1 file(s) 8 downloads |
ND | November 16, 2016 | Download |
Zinbryta PA Form 1 file(s) 6 downloads |
ND | November 16, 2016 | Download |
Zontivity PA Form 1 file(s) 7 downloads |
ND | November 16, 2016 | Download |