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