Provider Alert! 2023-24 RSV Season and Synagis Prior Authorization Begins Oct. 2 For Lower South Texas

Date: September 26, 2023

Attention: All Providers

Effective date: October 2, 2023

Call to action: Health and Human Services Commission (HHSC) will begin the 2023-24 Medicaid and CHIP-covered monthly prophylaxis for RSV on October. 2, 2023, for all counties in State Health Service Region 11. We will not open any other regions for Medicaid coverage of RSV prophylaxis at this time. Refer to the season schedule for each region’s start and end dates. HHSC will continue working with the Texas Pediatric Society’s task force to determine the RSV prophylaxis schedule for the other regions and will provide additional communication.

How this impacts providers: Prescribing providers must prescribe Synagis to infants meeting the criteria, unchanged from the 2022-2023 season, as described on the American Academy of Pediatrics website. 

HHSC accepts fee-for-service (FFS) prior authorization requests by fax and as early as September 25.  Prior authorization effective dates are based on the patient’s county of residence at the start of the season. Prescribing providers must use the Texas Department of Insurance (TDI) Texas Standard Prior Authorization Form for Prescription Drug Benefits for Synagis prior authorization requests.

Prior Authorization Forms

• Prescribing providers must use the Texas Department of Insurance (TDI) Texas Standard Prior Authorization Form for Prescription Drug Benefits for Synagis prior authorization requests.
  
• HHSC created the Synagis Standard Prior Authorization Addendum (HHS Form 1321) to accompany the TDI form. MCOs can use the HHSC addendum but should revise it to reflect appropriate contact information or prior authorization reconsideration processes.

NDC Information

The Synagis NDCs on the Medicaid formulary include the following:

• Synagis 100 MG/1 ml Vial (NDC 66658023101)
• Synagis 50 MG/0.5 ml Vial (NDC 66658023001)

Next steps for providers: Please review this information carefully. Providers should continue to follow American Academy of Pediatrics guidelines when prescribing.

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

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