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.
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.
Obtaining Prior Authorization
For the 2019-2020 RSV Season, the Synagis (palivizumab) eligibility criteria have not changed from the 2018-2019 season. Criteria continue to be based on the 2014 American Academy of Pediatrics (AAP) Guidelines for RSV prophylaxis, and follow HHSC’s Synagis clinical edit document.
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. The Navitus Provider Hotline (phone 1-877-908-6023) is also available to help identify plan-preferred pharmacies.
Lumicera Specialty Pharmacy
310 Integrity Drive
Madison, WI 53717
Synagis Phone, Providers: 1-855-847-3554
Synagis Phone, Patients: 1-855-847-3553
Synagis Fax: 1-855-847-3558
Email: contact@lumicera.com
Avella Specialty Pharmacy
3016 Guadalupe St, Ste A
Austin, TX 78705
Synagis Phone 877.470.7608
Synagis Fax 877.480.1746
RSV Season Dates
RSV 2019-2020 Season dates based on Region
Synagis Prior Authorization Forms
Synagis 2019-2020 prior authorization forms are posted below and will be accepted starting Tuesday, September 24th, 2019. Synagis will be active on the Texas Medicaid STAR Formulary on or around September 24. The Synagis PA forms may be used to request coverage for STAR or STAR Kids members for the health plans listed below.
Synagis – Children's Medical Center Health Plan (PDF)
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) (May be used to request coverage for CHIP)
Synagis – Scott & White Health Plan (PDF)
Synagis – Sendero Health Plan (PDF)
Synagis – Texas Children’s Health Plan (PDF)
Please contact Navitus Customer Care at 1-877-908-6023 with any questions.