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Reimbursement Criteria for Palivizumab (Synagis)

RSV Season

Palivizumab (Synagis) Clinical Authorization Criteria

Palivizumab Fax Cover Sheet and Clinical Authorization Form

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Mailing: Louisiana Department of Health | P.O. Box 629 | Baton Rouge, LA 70821-0629
Physical: 628 N. 4th Street | Baton Rouge, LA 70802 | Phone: 225.342.9500 | Fax: 225.342.5568
Medicaid Customer Service: 1.888.342.6207 | Healthy Louisiana: 1.855.229.6848