The 2017-18 respiratory syncytial virus season ended for all counties in Texas on April 14, 2018, and prior authorization requests for Synagis are no longer accepted or reviewed.

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. Traditional Medicaid Synagis Prior Authorization Request (HHS Form 1033)
  2. Traditional 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)