Prior Authorization Forms

General Forms

Drug Specific Request Forms

For the 2023/24 Synagis season, Neighborhood Health Plan of Rhode Island will prefer Beyfortus (nirsevimab), a long-acting monoclonal antibody, administered once to all neonates and infants entering their first RSV season as well as children up to 24 months who are high risk. Beyfortus will not require a prior authorization and will be available as a State Supplied Vaccine.

To obtain prophylactic treatment with Synagis, which requires six monthly injections, prescribers will need to submit a prior authorization documenting why the member is unable to utilize Beyfortus and clinical rationale showing the necessity of Synagis. To view Neighborhood’s Synagis Prior Authorization Criteria visit this page.

General Medical Authorization Request Forms