Beginning with the Fall/Winter traditional RSV season, HHSC will implement revised approval criteria for Synagis subsequent dosing (renewals). The changes will no longer require the dispensing pharmacy to check for members' weight nor confirm the previous dose was administered. The fall/winter traditional RSV season start date is not yet determined and is pending recommendation from the Texas Pediatric Society's RSV Task Force in coordination with HHSC.
HHSC will revise the Synagis Standard Prior Authorization Addendums for Medicaid (HHS Form 1321), and the CSHCN Services Program (HHS Form 1325) to reflect the changes. HHSC will make the forms available before the beginning of the RSV season.
The Synagis clinical prior authorization criteria (PDF) and policies are mandatory for managed care organizations (MCOs). The Pharmacy Clinical Prior Authorization Assistance Chart indicates which prior authorization each MCO uses. The chart is updated quarterly. Providers can also contact the MCO for each MCO's list of clinical prior authorizations.