August 12, 2020

The 2020-21 Respiratory Syncytial Virus (RSV) season begins Oct. 1, 2020, for many counties in Texas. HHSC will make the following changes this season to Synagis coverage and prior authorizations:

  • HHSC will not end-date NDCs for Synagis as in previous years and the drug will remain active on the formulary. Year-round access to Synagis on the formulary allows for consideration of off-season requests.
  • Access to Synagis for children in CHIP is available as a pharmacy benefit effective Sept. 1. The Medicaid prior authorization criteria also apply to CHIP. Synagis is not available as a medical benefit for CHIP.
  • Providers will use both the "Texas Standard Prior Authorization Request Form for Prescription Drug Benefits" and "Synagis Prior Authorization Addendum" for prior authorization requests.  
  • HHSC will remove the prior authorization criteria for the specialist or sub-specialist prescribing.

The schedule is staggered and is based on a patient's county of residence at the start of the RSV season. Refer to the Synagis season schedule for each region’s start and end dates.

Prior Authorization Requests

Traditional Medicaid

Providers obtain Synagis through the Vendor Drug Program and request prior authorization using the Standard Prior Authorization Request and addendum. Prescribing providers may submit prior authorization requests as early as Sept. 1. To obtain prior authorization, prescribing providers complete both forms and send them to the dispensing pharmacy. Pharmacy staff will fax the forms to the Texas Prior Authorization Call Center for processing. Providers can call 1-877-728-3927 for questions or assistance with the form.

Medicaid Managed Care and CHIP

Contact the patient’s MCO for prior authorization forms and instructions. Contact information is available on the Prescriber MCO Assistance Chart, or providers can refer to the MCO Resources for links to each MCO’s clinical prior authorizations.

Children with Special Health Care Needs Services Program

Providers obtain Synagis through the CSHCN Services Program and request prior authorization using the Standard Prior Authorization Request and addendum. Contact the CSHCN Services Program at 1-800-252-8023 for questions or assistance with the form.

Tags: 
Drug
RSV