Provider Alert! 2021-2022 Respiratory Syncytial Virus Season and Synagis (palivizumab)Texas Children's Health Plan
Date: July 23, 2021
Attention: All Providers
Treatment start date: October 1, 2021
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.
**This notice may be updated as new regions are opened or closed
Call to action: The traditional 2021-22 Respiratory Syncytial Virus (RSV) season is here! The Texas RSV Region schedule can be found on the Texas Health and Human Services (HHSC) Vendor Drug Program (VDP) website. Due to the highly unusual RSV activity during the 2020-21 season, need for Synagis should be re-assessed for eligible children in regions where RSV activity approaches the traditional fall-winter season.
For, these reasons, children who received doses of Synagis (palivizumab) during the summer RSV season will require reassessment as of October 1, 2021. Children who may need additional doses of Synagis (palivizumab) due to age and clinical condition will require the completion of a new prior authorization process for possible additional doses. In this sense, the traditional 2021-22 RSV season will be considered a new season beginning October 1, 2021, separate from the unusual summer season.
How this impacts providers: Guidance regarding prior authorization for Synagis is as follows:
- For members who receive summer doses of Synagis and need additional doses, providers will need to initiate a new prior authorization request after October 1st
- Similar to last year, TCH pharmacies will fulfill Synagis authorizations upon request from TCH providers (Greenspoint, Southwest, TCH Main Campus). The PA forms can be provided by the pharmacy department.
- Walmart Specialty Pharmacy and Lumicera Specialty will continue to be options for all providers.
- 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.
- We recommend resubmitting for subsequent doses closer to the time the next dose is due. This will avoid issues with the 10-day adjudication window, or potential refill too soon rejections at the pharmacy.
- Up to five (5) monthly doses total may be authorized throughout RSV season. Each subsequent dose after the initial dose must be requested with a prior authorization form completed by the dispensing pharmacy.
- The dispensing pharmacy is required to obtain confirmation of all administered doses from the provider, including any inpatient doses that may have been given.
- Information about Synagis can be found on the Navitus website including PA forms: https://txstarchip.navitus.com/pages/synagis.aspx
- The TDI standard PA authorization request form can be found here: https://txstarchip.navitus.com/pdf-documents/pa-forms/texas-standard-prior-authorization-request-form.aspx
- The Synagis PA authorization request form for TCHP can be found here: https://txstarchip.navitus.com/pdf-documents/pa-forms/synagis-2019-2020_tx-mcaid_092419-(9).aspx
- Subsequent PA forms can be found here: https://txstarchip.navitus.com/pdf-documents/other/synagis-renewal_tx-mcaid_090120.aspx
Next steps for providers: Providers should share this communication with their staff. Updated guidance will be posted on the TX Vendor Drug Program website.
If you have any questions, please email Provider Network Management at: email@example.com.