Provider Alert! Synagis Administration as a Home Health Service

Attention: All Providers

Effective Date: November 23, 2020

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: Texas Children’s Health Plan (TCHP) aligns with the Health and Human Services Commission (HHSC) to provide expanded access to Synagis. Synagis may now be provided with home health services for qualified members.

Synagis (palivizumab) is a monthly prophylactic injection administered to high-risk children during the Respiratory Syncytial Virus season. Synagis is available as an outpatient pharmacy benefit with a prior authorization (PA) for members enrolled in Medicaid and CHIP.

Due to COVID-19 concerns, TCHP will approve home health benefits for Synagis administration in the home for people who already receive nursing services. This will allow TCHP to better serve members with complex health challenges.

How this impacts providers: Synagis administration as a home health service follows the following guidelines:

• TCHP may approve requests for Synagis home health administration provided the person already receives nursing services at home.
• Consideration should occur after the required clinical PA for Synagis is complete and approved.
• TCHP has the authority with their respective Pharmacy Benefit Manager (PBM) to coordinate home health services without requiring Vendor Drug Program (VDP) approval each time.
• A physician’s order must be present either on the plan of care form or as a supplemental order for the administration of Synagis injections during the RSV season.
• If a physician, other than the physician ordering home health nursing or private duty nursing services, prescribes Synagis injections, it is the home health agency’s responsibility to ensure that the additional order for the administration of Synagis injections is in place.
• Providing at-home administration of Synagis rather than in a clinical setting would help minimize concerns for COVID-19 exposure for medically fragile children.

Resources:

Navitus Synagis prior authorization general information: https://txstarchip.navitus.com/pages/synagis.aspx

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 – Texas Children’s Health Plan (PDF)

Renewal Request Forms
Subsequent Dose (Renewal) form – All health plans (PDF)

Next steps for providers: Providers should communicate these changes to their staff.

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

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