Synagis

Respiratory Syncytial Virus (RSV) Season has Opened for Select Regions of the State

Texas Health and Human Services Commission (HHSC) has determined the 2023-2024 Respiratory Syncytial Virus (RSV) season for the coverage of Synagis (palivizumab) will begin for select regions on October 2, 2023. Prior authorization requests may be submitted for review for members residing in open regions beginning on Monday, September 25, 2023. Additional regions may open at later dates as determined by HHSC.

Please see the “Synagis Prior Authorization Forms” section below for information on how to request coverage for Synagis (palivizumab).

About RSV Season and RSV Prophylaxis

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. Two products are currently available to help prevent RSV infections in young children: Beyfortus and Synagis.

Beyfortus (nirsevimab) is a one-time intramuscular injection to prevent severe RSV infections in newborns and children under one year old who are born during or entering their first RSV season. Children up to 24 months old who remain at high risk of severe RSV infection through their second RSV season may also receive Beyfortus. Beyfortus is available through the Texas Vaccines for Children (TVFC) Program and is given by TVFC providers. It is not covered by the pharmacy benefit.

Synagis (palivizumab) is a monthly intramuscular injection for infants and children up to 24 months old at the RSV season start who are at high-risk for severe RSV infections. Patients receive up to five (5) monthly doses of Synagis during the local RSV season. Synagis is available under the pharmacy benefit and requires prior authorization. Patients who have received Beyfortus at any time during the current RSV season should not receive Synagis injections.

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 2023-2024 Season Dates Based on Region

Obtaining Prior Authorization for Synagis

For the 2023-2024 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 2023-2024 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) 2023-2024 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-11 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-11 (Certification on File) 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 877-908-6023) is also available to help identify plan-preferred pharmacies.