Synagis® Program

Synagis® is a prescription medication that is used to help prevent a serious lung disease caused by respiratory syncytial virus (RSV) in infants and children at high risk for severe lung disease from RSV.

Prior approvals for Synagis will be available through the Vendor Drug Program beginning September 15, 2011.

2011-12 RSV Season

Based on statistics from previous respiratory syncytial virus (RSV) seasons, the start of the 2011-12 Synagis® season will be based on the county of residence. The statistics from previous years indicate RSV appears earlier in some counties and remains active later in other counties. Most of the counties in the state will start the season October 1, 2011 and end February 28, 2012. Counties in the western part of the state will start November 1, 2011 and end March 31, 2012.

Obtaining Synagis® through the Vendor Drug Program:

1. The treating provider identifies a Medicaid-enrolled client with indications for Respiratory Syncytial Virus (RSV) prophylaxis with Synagis®.
2. The provider or provider's agent sends a prescription for Synagis® with supporting clinical information on the Texas Medicaid Prior Authorization request form to a Texas Medicaid-enrolled pharmacy that is a member of the Synagis® Distribution Network.  Please do not submit multiple request forms.
3. The pharmacy faxes the completed Texas Medicaid prior authorization request and prescription form to the Texas Prior Authorization Call Center at 1-866-617-8864. Prior authorization is required for all patients. The pharmacy should include their telephone and fax number on the prescription form. Pharmacies should call the Texas Prior Authorization Call Center at 1-877-PA Texas (1-877-728-3927) for any questions related to submitted prior authorization request forms.
4. If the information submitted does not demonstrate medical necessity (based on Medicaid medical benefits policy adapted from the American Academy of Pediatrics guidelines), the request is denied. Both the pharmacy and provider are notified of the denial.
5. If the information submitted does demonstrate medical necessity, the request is approved and both pharmacy and provider are notified.
6. If the prior authorization is approved, the dispensing pharmacy fills the prescription and overnight ships an individual dose of the medication, in the name of the Medicaid client, directly to the provider. An initiation packet also is mailed by the dispensing pharmacy to the client's family, informing them of RSV, Synagis® and its effects.
7. The physician or provider under the direct supervision of the physician administers the Synagis® injection to the Medicaid client.
8. The injection provider may only bill for an injection administration fee and any medically necessary office-based evaluation and management service provided at the time of injection. The pharmacy provider is reimbursed for the drug and dispesing fees.
9. Before shipping and billing for a subsequent dose, the pharmacy must contact the injection provider to:
• Obtain updated patient information (e.g. weight) to ensure the need and proper amount for the next dose.
• Verify that the patient was administered all previously dispensed Synagis® prescriptions.
• Pharmacies should maintain a log of the information obtained from the injecting provider.

Reminder: as per the American Academy of Pediatrics guidelines, Medicaid clients approved for Synagis® are limited to five injections for the season.

Notes: The traditional option to purchase and bill through the Texas Medicaid & Healthcare Partnership (TMHP) is still available as in past RSV seasons.  Contact the Medicaid health maintenance organization (HMO) for Medicaid clients that are enrolled health plan members.  Contact the Children's Health Insurance Program (CHIP) health plan for clients enrolled in CHIP.

• Participating Pharmacies
• Synagis County Schedule
• Synagis Prescription Request Form