To Initiate a first time Makena order for your patient, please fill out our Enrollment Form and fax or email it to us. Please note that the Makena form is not a prescription. You still need to forward us an Official NYS Prescription form, call it in verbally, or e-scribe it to us.
Procedure for Synagis Referrals
1. After you obtain a prior authorization fax the statement of medical necessity (aka referral) form to 516-292-5103, along with the prior authorization information (pa # and dates of auth)
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 15 mg/kg/dose IM QM REFILLS X 4
- b. Synagis 100mg/ml dispense 1 vial 15 mg/kg/dose IM QM REFILLS X 4
- c. Synagis 100mg/ml dispense 2 vials 15mg/kg/dose IM QM REFILLS X 4
- 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 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.
- 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