Synagis Clinical Prior Authorization Forms Updated With Revised Criteria

On Nov. 17, 2023, HHSC updated the Medicaid and CSHCN Synagis Standard Prior Authorization Requests to include a step to check for Abrysvo vaccine administration to the client’s mother during 32 to 36 weeks of pregnancy.

Abrysvo is indicated for active immunization of pregnant individuals at 32 through 36 weeks gestational age for the prevention of lower respiratory tract disease (LRTD) and severe LRTD caused by respiratory syncytial virus (RSV) in infants from birth through 6 months.

Infants whose mothers were vaccinated at the appropriate time may have full protection against RSV and should not need further prophylaxis therapy with Synagis and MCOs should deny the prior authorization request.  Since this immunization is time-sensitive, if the mother was vaccinated several weeks before the RSV season, the infant may need further treatment with either Synagis or Beyfortus to ensure protection against RSV throughout the entire season.

The revised forms include the following:

• Synagis Standard Prior Authorization Request (Medicaid) (HHS Form 1321)
• Synagis Standard Prior Authorization Request (CSHCN) (HHS Form 1325)