Respiratory Syncytial Virus (RSV) Season Restarts Statewide October 17, 2022
Texas Health and Human Services Commission (HHSC) together with Texas Pediatric Society’s Respiratory Syncytial Virus (RSV) Taskforce have determined the Fall/Winter 2022-2023 Respiratory Syncytial Virus (RSV) season for the coverage of Synagis (palivizumab) will officially restart statewide on October 17, 2022. Members who were approved for doses over the summer and early fall must have new initial requests submitted for consideration of continued Synagis coverage through the fall and winter seasons.
Viral activity continues an unusual trend this year and the RSV season has not followed the typical pattern of previous years. The season for these regions may close earlier than in the past as HHSC continues to monitor RSV virology reports across the state. Please see the "Obtaining Prior Authorization" section below for information on how to request coverage of this product.
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 and will be accepted starting Monday, October 17th, 2022. 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
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.
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.
Lumicera Specialty Pharmacy
Synagis Phone - Providers 1.855.847.3554
Synagis Phone - Patients 1.855.847.3553
Synagis Fax 1.855.847.3558
Email contact@lumicera.com
Walmart Specialty Pharmacy
Synagis Phone 1.877.453.4566
Synagis Fax 1.866.537.0877
Please contact Navitus Provider Hotline at 1.877.908.6023 with any questions.