Aug. 31: Respiratory Syncytial Virus Season Begins Oct. 1

Medicaid Managed Care

Prescribing providers and pharmacy staff should contact the appropriate health plan for prior authorization requirements using the contact information on the Prescriber MCO Assistance Chart (PDF).

Traditional Medicaid

Please use either form #1 or #2 to and submit the completed form to the Texas Prior Authorization Call Center.

  1. Medicaid Synagis Prior Authorization Request (HHS Form 1033)
  2. Medicaid Synagis Prior Authorization Request Addendum (HHS Form 1321)

CSHCN Services Program

Please use either form #1 or #2 and submit completed forms to the CSHCN Services Program.

  1. CSHCN Services Program Synagis Authorization Request (HHS Form 1055)
  2. CSHCN Services Program Synagis Authorization Request Addendum (HHS Form 1325)