Procedure For Synagis Referrals
1.Fill out the statement of medical necessity (aka referral) form completely making sure prescriber signs it and fax to 516-292-5103. Include discharge summary, progress/clinical notes, etc.
2.PRESCRIPTIONS (Send electronically when possible):
Synagis is given 15mg/kg IM monthly. Prescribe either 50mg, 100mg, or 2 X 100mg determined by patients weight, or you may send all of the following to cover the patient throughout the season for weight gain.
a. Synagis 50mg/0.5ml dispense 1 vial 15mg/kg/dose IM QM REFILLS X4
b. Synagis 100mg/ml dispense 1 vial 15mg/kg/dose IM QM REFILLS X4
c. Synagis 100mg/ml dispense 2 vials 15mg/kg/dose IM QM REFILLS X4
d. Epinephrine* vial 1:1000 dispense 1 vial 0.01mg/kg SQ PRN ANAPHYLAXIS
3.To reorder Synagis, please fill out the reorder form that will also be included in your Synagis delivery.
If you have any questions, please do not hesitate to call us.
Thank you, Your Synagis Team
*Epinephrine is needed when requesting home care for patient, or if prescriber feels it is necessary–please note that not all insurances pay for epinephrine without prior authorization. If it requires a PA, we will contact you so that you can obtain it.
Contracted Plans with Synagis
- Affinity Health Plan
- Fidelis Care (NYS Catholic Health Plan)
- Healthnet of the Northeast
- Hudson Health Plan/MVP Healthcare
- Medicaid (straight, fee for service)
- Neighborhood Health Plan
This list is continually updated. Please call if your patient’s insurance is not listed.