Provider Alert! RSV Fall/Winter Traditional Season Regional Changes Begin October 17

Date: October 17, 2022

Attention: All Providers 

Effective Date: October 17, 2022

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: Traditional Respiratory Syncytial Virus (RSV) season is here. Texas Children’s Health Plan (TCHP) would like to let providers know that effective October 17, 2022, the Texas Health and Human Services (HHSC) will open all eleven Texas Public Health Service regions to Palivizumab (Synagis) prophylaxis for an anticipated traditional 2022-23 Fall/Winter Respiratory Syncytial Virus (RSV) season. For clinical prior authorization purposes, the 2022-23 Fall/Winter traditional RSV season is considered a new season beginning October 17, separate from the summer season.

How this impacts providers: Guidance regarding prior authorization for Synagis is as follows:

1. Similar to STAR and STAR KIDS, Synagis for CHIP members will only be available through the pharmacy benefit. The prior authorization criteria will be the same for all members.
2. A new prior authorization request is required for all members who meet the criteria for RSV prophylaxis.
3. Providers will only need to submit the initial PA approval request for up to five (5) doses per treatment course
   • 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.
   • Walmart Specialty Pharmacy and Lumicera Specialty will continue to be options for all providers.
4. Providers will need to submit both the Texas Department of Insurance (TDI) Synagis PA form as well as the TCHP Standard PA form request.

• The TCH Centers Pharmacies have customized PA forms available specific to the Centers Pharmacies.
• Prior authorization forms can be found on Navitus page.

5. Pharmacies are required to submit refill prior authorization requestsfor each subsequent dose
   • The dispensing pharmacy will no longer be required to check for members’ weight nor confirm the previous dose was administered
   • Updated renewal request forms can be found on Navitus page

Next steps for providers: Refer to the 2022-2023 RSV season schedule for information regarding start and end dates for all regions. Providers should continue to follow American Academy of Pediatrics guidelines when prescribing and should share this communication with their staff.

Resources: Synagis Standard Prior Authorization Addendum (Medicaid)

• 1321 (attached)

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