Synagis

Synagis Prescribers:

RSV Season
The start and end of each respiratory syncytial virus (RSV) season is based on the client’s county of residence. RSV appears earlier in some counties and remains active later in other counties. The 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 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.

Synagis Prior Authorization Criteria
For the 2018-2019 RSV Season, the Synagis (palivizumab) eligibility criteria has not changed from the 2017-2018 Season. Criteria continue to be based on the 2014 American Academy of Pediatrics (AAP) Guidelines.

Synagis Access Information
Please note some health plans may prefer pharmacies other than those listed. Please see the health plan-specific prior authorization forms (linked below) for available pharmacies.

Synagis Pharmacy Providers:

RSV 2018-2019 Season dates are based on Region: https://www.txvendordrug.com/formulary/prior-authorization/synagis/schedule

Synagis 2018-2019 prior authorization forms are posted below and will be accepted starting on Monday, September 24th, 2018. The Synagis PA forms may be used to request coverage for STAR, STAR Kids or CHIP members for the health plans listed below.

• Children's Medical Center Health Plan
• Community First Health Plan
• Community Health Choice
• Cook Children's Health Plan
• Driscoll Children's Health Plan
• El Paso First Health Plan
• FirstCare Health Plan
• Parkland Community Health Plan
• Scott & White Health Plan
• Seton Health Plan
• Texas Children's Health Plan

References
Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection. Pediatrics. 134:2 (2014): 415-20.