Forms & Documents

Complete Synagis prior authorization form and fax to Navitus at 855-668-8551. You will receive a fax indicating approval or denial of prior authorization determination is made. If request is approved, fax order for Synagis to Lumicera Specialty Pharmacy at 855-847-3558. If you wish to have a home health agency administer Synagis to your patient, please indicate that the medication will be shipped to the patient’s home on your order. Upon receipt of Synagis order indicating that medication will be shipped to patient’s home, Lumicera will fax a home health request to Colorado Access utilization management (UM) team to set up the services. Our UM team will work to set up a home health agency to visit the patient’s home and administer the medication.

Synagis is covered for eligible patients through the Colorado Access pharmacy benefit. The specific criteria for approval can be found here. Prior authorization forms should be faxed to Navitus at 855-668-8551.