Respiratory Syncytial Virus Treatment
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
Manual
Forms
- Medicaid managed care and 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