Date: October 4, 2024
Attention: All Providers
Effective Date: October 1, 2024

Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that effective October 1, 2024, the Texas Health and Human Services (HHSC) will open all counties in State Health Service to Palivizumab (Synagis) prophylaxis for 2024-25 Fall/Winter Respiratory Syncytial Virus (RSV) season. Refer to the season schedule for each region's start and end dates.

How this impacts providers: HHSC will accept fee-for-service (FFS) prior authorization requests by fax and as early as September 23, 2024.

Prescribing providers must prescribe Synagis to infants meeting the criteria as described on the American Academy of Pediatrics website.

• Similar to STAR and STAR Kids, Synagis for CHIP members will be available through the pharmacy benefit. The prior authorization criteria will be the same for all members.
• A new prior authorization request is required for all members who meet the criteria for RSV prophylaxis
• Providers will only need to submit the initial PA approval request for up to five (5) doses per treatment course
  • Approvals will be limited to one (1) monthly dose at a time. The approval will only allow for a 10-day window for pharmacy adjudication. The provider should hold the member’s Synagis vial(s) until that dose can be administered to prevent potential for missed doses.
• Providers will need to submit BOTH the Texas Department of Insurance (TDI) Synagis PA form as well as the Standard PA form initial request
  • Prior authorization forms can be found on Navituspage
• Pharmacies are not required to submit refill prior authorization requests for each subsequent dose
• Texas Health and Human Services (HHSC) created the Synagis Standard Prior Authorization Addendum (HHS Form 1321) to accompany the TDI form, and revised it to reflect Beyfortus use.
• Providers will only need to submit the initial PA approval request, approvals will be granted for up to five (5) doses per treatment course
• Please note subsequent dose forms are not required for the 2024-2025 RSV season. Please be advised, members who have been hospitalized for an RSV infection during RSV season may be denied further refills for Synagis. 
• AcariaHealth Pharmacy and Lumicera Specialty Pharmacy will be the preferred options for all providers.

2024-25 Synagis Prior Authorization Schedule:

Updated as of September 24, 2024. Refer to HHSC’s website for the most up-to-date information.

Providers can find their region using theinteraction region map (PDF)and selecting the buttons marked HHS regions and county names.

Table 1: Region Dates

Additional Products for RSV:

The Food and Drug Administration (FDA) approved several new products for RSV prevention this year, including:

• Beyfortus (nirsevimab – monoclonal antibody – AstraZeneca/Sanofi) is administered as a one-time intramuscular dose for the prevention of severe RSV infections in newborns and babies under one year, born during or entering their first RSV season, as well as children up to 24 months who remain at risk of severe RSV disease through their second RSV season. The Texas Vaccine for Children Program (TVFC) provides this medication. It is not covered by the pharmacy benefit
• Abrysvo (RSV preF vaccine - Pfizer) is indicated as a single dose for the prevention of lower respiratory tract disease (LRTD) caused by RSV in people 60 years and older, as well as pregnant individuals at 32 through 36 of gestation for the prevention LRTD and severe LRTD caused by RSV in infants from birth through 6 months of age.
• Arexvy (RSV PreF3 vaccine - GSK) is indicated as a single dose for preventing LRTD caused by RSV in people 60 years of age and older.

The Vendor Drug Program does not cover these products as a pharmacy benefit. Nirsevimab, intended for children, is available through TVFC. The other vaccines are available through the Medicaid medical benefit.

Next steps for providers: Refer to the 2024-2025 RSV season schedule for information regarding start and end dates for all regions. Providers should continue to follow American Academy of Pediatrics guidelines when prescribing and should share this communication with their staff.

Resources:

• Synagis
• Texas DSHS Infectious Disease Control: Respiratory Syncytial Virus
• Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook of the Texas Medicaid Provider Procedures Manual (TMPPM).
• Centers for Disease Control and Prevention: Respiratory Syncytial Virus Infection (RSV)

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org. 

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