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Synagis referral form

Optum Specialty RSV referral form for Synagis.

This is an Optum prior authorization criteria specific form to enroll or prescribe RSV and Synagis treatment from Optum Specialty Pharmacy.

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Synagis Season Updates

  1. Optum Specialty Pharmacy does not coordinate Nursing Services for Synagis. If in-home administration is preferred, the MD Office must secure nursing prior to our pharmacy shipping the medication to the home.
  2. Optum Specialty Pharmacy does not fulfill referrals with a non-contracted Medicaid Secondary plan. Providers may contact the patient's plan for alternative options.