Provider Alert!Criteria Changes for Subsequent Dosing of Palivizumab (Synagis) with Fall/Winter Traditional Respiratory Syncytial Virus Season

Date: October 5, 2022

Attention: All Providers

Effective Date: Fall/Winter traditional RSV season

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 Health Plan (TCHP) would like to inform providers that Palivizumab (Synagis) prior approval criteria will change for subsequent dosing with Fall/Winter traditional Respiratory Syncytial Virus (RSV) season.

How this impacts providers: Beginning with the Fall/Winter traditional RSV season, TCHP will revise Synagis approval criteria for subsequent dosing (renewals). The dispensing pharmacy will no longer be required to check for members’ weight nor confirm the previous dose was administered. The revised criteria for renewals will be as follows:

1. Has the client been hospitalized for RSV since the last palivizumab dose?

[ ] Yes (Deny)

[ ] No (Go to #2)

2. Are there greater than (>) 4 dates of service for palivizumab since the beginning of the current RSV season (determined by client’s county of residence) until today?

[ ] Yes (Deny)

[ ] No (Go to #3)

3. Is the claim for 1 vial of either the 50mg or 100mg vials?

[ ] Yes (Approve – 10 days)

[ ] No (Deny)

Once renewal request forms are updated, they can be found on Navitus page. The start of the Fall/Winter traditional RSV season has not been determined, but TCHP will announce the traditional RSV season start date once we receive a recommendation from the state.

Next steps for providers: Providers should continue to follow American Academy of Pediatrics guidelines when prescribing and should share this communication with 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