Provider Alert! 2021-2022 Respiratory Syncytial Virus Season Now Open in all Regions
Date: July 23, 2021
Attention: All Providers
Treatment start date: June 21, 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: Respiratory Syncytial Virus (RSV) activity has been highly unusual during the 2020-21 season. Initially, virology reports indicated very few cases of RSV infections. However, following the reopening of schools, relaxation of COVID-19 restrictions related to social distancing, and reduced use of personal protection equipment, there are reports of RSV resurgence in several regions of Texas.
For these reasons, as of July 23, 2021, the Health and Human Services Commission (HHSC) will open all Department of State Health Services (DSHS) regions, and providers may start monthly Palivizumab (Synagis) injections for RSV prophylaxis for clients who meet clinical criteria. This is considered the start of a new RSV season, separate from the traditional 2020-21 RSV season. At this time, clients who meet the prior authorization criteria are qualified for up to five monthly shots of Palivizumab (Synagis). Providers may start monthly palivizumab (Synagis) prophylaxis treatment for all eligible members on June 21, 2021.
How this impacts providers: Guidance regarding prior authorization for Synagis is as follows:
- For members who have previously met prior authorization approval criteria and received all five monthly prophylaxis injections during the season:
- It is not necessary for Providers to initiate a new prior authorization request.
- Prior authorization requests for members who received all doses during the “regular” RSV 2020-21 season will be denied. Providers must submit appeals for a sixth (or more) dose.
- For members who have not received any injections during the season:
- Providers must fax the Texas Standard Prior Authorization Form for Prescription Drug Benefits (TDI form NOFR002) and the addendum form. These are handled as initial or “new” requests.
- Approvals are only authorized for a 10-day window per HHSC guidelines.
- For members who received 1-4 monthly doses during the “regular” RSV 2020-21-season:
- Providers need to submit renewal Synagis Prior Authorization forms. These are handled as “refill” requests. Approvals are only authorized for a 10-day window per the Synagis clinical edit.
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.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.