Human Respiratory Syncytial Virus (RSV) causes respiratory tract infections and severe lung disease in infants and children. Synagis (palivizumab) is available for children with a high risk of infection.

Pharmacy Information

Any specialty pharmacy enrolled with HHSC may dispense and ship Synagis to the prescribing provider. A pharmacy must enroll in the CSHCN Services Program to provide services to children in the program.

Prescribing Provider Information

The administering provider may only bill Medicaid through the Texas Medicaid Healthcare Partnership (TMHP) for an injection administration fee and any medically necessary office-based evaluation and management services provided at the time of injection. For administration billing information, prescribing providers may refer to the "RSV Monoclonal Antibody Nirsevimab Is a Benefit of Texas Medicaid" notice.

Schedule

• 2024-25 RSV Schedule

Forms

• Medicaid managed care and CHIP:
  • Contact each MCO for copies of its prior authorization forms.
• Traditional Medicaid:
  • Prescribing providers must complete the TDI Standard Prior Authorization Request and HHS Form 1321. The provider submits the form as instructed.
• CSHCN Services Program:
  • Prescribing providers must complete the TDI Standard Prior Authorization Request and HHS Form 1325. The provider submits the form as instructed.

Contact

• Medicaid managed care, CHIP:
  • Each MCO’s prior authorization form reflects the appropriate MCO contact information and reconsideration request process.
• Traditional Medicaid:
  • Contact the Texas Prior Authorization Call Center as described on the form
• CSHCN Services Program:
  • Contact the CSHCN Service Program as described on the form