Human Respiratory Syncytial Virus (RSV) causes respiratory tract infections and serious lung disease in infants and children. Synagis (palivizumab) is available for children with high risk of infection. The 2020-21 respiratory syncytial virus (RSV) season begins Oct. 1.

Formulary Coverage

  • Synagis becomes a year-round benefit for Medicaid, CHIP, and CSHCN Services Program to allow for consideration of off-season requests. VDP will not end-date NDCs for Synagis as in previous years and will remain active on the formulary.
    • RSV illness may occur at any time during the year, but most cases occur in a season from late autumn to early spring, peaking in mid-winter. VDP coverage for the series of 5 once-monthly doses of Synagis prophylaxis for RSV is based on this season. Since this season varies across the 11 Texas Health Service Regions, Synagis prophylaxis coverage may start earlier or last later in one region versus others.
    • An RSV Taskforce determines the beginning and end of the season in each region by reviewing the percentage of positive reported RSV tests as they rise and fall with disease activity. The taskforce previously relied on RSV antigen testing but may rely more on PCR testing in the future.
  • Synagis for children in CHIP is a pharmacy benefit beginning Sept. 1, 2020, and no longer available as a medical benefit. The Medicaid prior authorization criteria also apply to CHIP and align coverage as a pharmacy benefit for both programs.

Forms

Prescribing providers must complete the Texas Standard Prior Authorization Form for Prescription Drug Benefits (Texas Department of Insurance form NOFR002), for all requests. Addendum forms are used alongside the TDI form to provide the necessary clinical information specific to Synagis.

  • Traditional Medicaid requires NOFR002 and addendum HHS Form 1321
  • CSHCN Services Program requires NOFR002 with addendum HHS Form 1325
  • Medicaid managed care and CHIP require NORFR002 and may provide additional information with the specific MCO addendum form or via phone call. The MCO’s Synagis prior authorization form reflects the appropriate MCO contact information and reconsideration request process.

Requests

  • Traditional Medicaid will accept TDI form and HHS addendum by fax as early as Sept. 1, 2020.
  •  Medicaid managed care plans may begin processing Synagis prior authorization requests up to 16 business days before a region's RSV season start date. Prior authorization effective dates are based on the patient’s county of residence at the start of the season.

Criteria

The prior authorization criteria used this season are the same as last year’s season except for the requirement for a specialist or sub-specialist prescribing for patients not meeting the approval criteria listed on the addendum form yet health-wise are at high risk of developing severe RSV infection or hospitalization.

Pharmacy Information

Any specialty pharmacy enrolled with HHSC may provide Synagis. A pharmacy must be enrolled in the CSHCN Services Program to provide services to children in the program.

Contacts