Synagis Prior Authorization Guidance - Reminder

Date: December 28, 2022

Attention: All Providers

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Beginning with the 2022-23 Human Respiratory Syncytial Virus (RSV) season, the Texas Health and Human Services Commission (HHSC) implemented simplified approval criteria for Synagis subsequent dosing (renewals). Pharmacies will no longer be required to coordinate with providers’ offices for subsequent refill authorizations.

How this impacts providers There are no immediate changes for providers. Members will only require one prior authorization approval for Synagis prophylaxis and may apply it to up to five monthly doses per treatment course.

However, providers should be aware that subsequent refills will be denied if the member experiences breakthrough RSV hospitalization. Providers should notify Texas Children’s Health Plan and the dispensing pharmacy if members are hospitalized.

Next steps for providers: Providers should share this communication with their staff. The Synagis Prior Authorization Addendum for Medicaid (HHSC Form 1321) is available for reference.

If you have any questions, please email TCHP Pharmacy at: TCHPPharmacy@texaschildrens.org.

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.