Synagis

Respiratory Syncytial Virus (RSV) Season Has Ended

Texas Health and Human Services Commission (HHSC) has determined the 2022-2023 Respiratory Syncytial Virus (RSV) season for the coverage of Synagis (palivizumab) is over. This decision was based on the recommendation of the Texas RSV task force and HHSC Office of the Medical Director. The traditional RSV season began on October 17, 2022, and ended on March 1, 2023, for all regions of the state.

Off-season requests for coverage of Synagis (palivizumab) may be considered on a case-by-case basis. Please see the “Synagis Prior Authorization Forms” section below. Medical rationale for off-season use should also be submitted with the request.

About RSV Season

Human Respiratory Syncytial Virus (RSV) is a common and very contagious virus that infects the lungs and respiratory system. It can cause serious lung disease in infants and young children. Synagis (palivizumab) is available with prior authorization for young members who are at high risk of complications from RSV infection.

RSV infections are most common from late autumn to early spring, with the most infections occurring during the winter months. The start and end of RSV season is based on the member’s county of residence. RSV appears earlier in some counties and remains active later in other counties. Texas Health and Human Services Commission (HHSC) uses statistics from prior years in addition to current virology reports to determine the start and end dates for each local region. HHSC reserves the right to end or extend the season after review of RSV levels in each region. Health plan medical directors are allowed to end the RSV season for a health plan, by service area, if the plan can demonstrate to HHSC that the local virology has dropped below 10% positivity for two consecutive weeks.

RSV Season Dates

RSV 2022-2023 Season Dates Based on Region

Obtaining Prior Authorization

For the 2022-2023 Traditional Fall/Winter RSV Season, the Synagis (palivizumab) eligibility criteria continue to be based on the 2014 American Academy of Pediatrics (AAP) Guidelines for RSV prophylaxis. Criteria follow HHSC’s Synagis clinical edit document, with the exception that initial requests will be approved for the duration of the whole RSV season as allowed by HHSC.

Initial requests must include BOTH the Texas Standard Prior Authorization form AND the health plan’s Synagis Prior Authorization form (Form 1321 equivalent). Failure to submit BOTH forms will result in denial of the request. After initial approval, subsequent doses may be obtained from the dispensing pharmacy per usual refill processes. Up to five (5) monthly doses of Synagis will be approved during the RSV season where medically necessary. Members may not receive all five doses depending on when the state determines their local RSV season has ended.

Synagis Prior Authorization Forms

Synagis 2022-2023 Traditional Season (Fall/Winter) Initial Request prior authorization forms are posted below. The Synagis PA forms may be used to request coverage for STAR, CHIP or STAR Kids members for the health plans listed below. Synagis remains active on the Texas Medicaid STAR and CHIP Formularies year-round.

Initial Requests

Initial requests require BOTH the Texas Standard Prior Authorization form AND the Synagis request form (Form 1321 equivalent) be filled out by the prescriber. The prescriber completes both forms and sends them to the pharmacy indicated on the Synagis form. The pharmacy will then forward the requests to Navitus for review. Approvals will be granted for up to five (5) monthly doses through the member's local RSV season. Failure to submit both prior authorization forms will result in denial of the request.

Subsequent Dose Forms

Subsequent dose forms are not required for the Traditional (Fall/Winter) 2022-2023 RSV Season. Please be advised, members who have been hospitalized for an RSV infection during the RSV season may be denied further refills of Synagis. All Synagis claims for members with approvals on file will reject with a message stating “pharmacy submit SCC-7 if member has NOT been hospitalized for RSV since last dose or if first fill”. Pharmacies must verify the member has NOT been hospitalized for an RSV infection and then resubmit the claim with SCC-7 (Medically Necessary) populated. Synagis claims missing this information may not adjudicate.

Initial Request Forms – both forms are required

The Texas Standard Prior Authorization form must be submitted with the health plan specific form below.

Texas Standard Prior Authorization Form
Standard PA form (PDF)

Health Plan Specific forms (must be submitted with standard form above)
Synagis – Community First Health Plan (PDF)
Synagis – Community Health Choice (PDF)
Synagis – Cook Children’s Health Plan (PDF)
Synagis – Dell Children's (Seton) Health Plan (PDF)
Synagis – Driscoll Children’s Health Plan (PDF)
Synagis – El Paso Health Plans (PDF)
Synagis – FirstCare Health Plan (PDF)
Synagis – Parkland Community Health Plans (PDF)
Synagis – Scott & White Health Plan (PDF)
Synagis – Texas Children’s Health Plan (PDF)

Renewal Request Forms - no longer required

Pharmacy Information

Please note some health plans may prefer pharmacies other than those listed. Please see the health plan-specific prior authorization forms (linked above) for available pharmacies. The Navitus Provider Hotline (phone 1.877.908.6023) is also available to help identify plan-preferred pharmacies.