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 2020-2021 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.
Initial requests must include BOTH the Texas Standard Prior Authorization form AND the health plan’s Synagis Prior Authorization form. Failure to submit BOTH forms will result in denial of the request. After initial approval, subsequent doses should be requested by the dispensing pharmacy by submitting the Subsequent Dose (Renewal) form. See below for more information.
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
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
RSV Season Dates
RSV 2020-2021 Season dates based on Region
Synagis Prior Authorization Forms
Synagis 2020-2021 Initial Request and Subsequent Dose prior authorization forms are posted below and will be accepted starting Tuesday, September 1st, 2020. The Synagis PA forms may be used to request coverage for STAR, CHIP or STAR Kids members for the health plans listed below. Synagis will be active on the Texas Medicaid STAR Formulary on or around September 21st.
Initial Requests require BOTH the Texas Standard Prior Authorization form AND the Synagis request form 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 are only granted for one dose at a time. Failure to submit both prior authorization forms will result in denial of the request.
Subsequent Dose forms are used to request each dose after the initial approval. Members may be approved for up to five total doses during their local RSV season. The Subsequent Dose forms are filled out by the dispensing pharmacy and forwarded to Navitus for review. The dispensing pharmacy will contact the prescriber office for the information needed on this form including dates of previous Synagis doses, current weight, and if a hospitalization due to an RSV infection has occurred. Approvals are only granted for one dose at a time and outreach to the prescriber office is expected prior to each monthly dose requested.
Initial Request Forms – both forms are required
Texas Standard Prior Authorization form (must be submitted with health plan specific form below)
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
Subsequent Dose (Renewal) form – All health plans (PDF)
Please contact Navitus Customer Care at 1.877.908.6023 with any questions.