Provider Alert! Respiratory Syncytial Virus (RSV) Prophylaxis Season Reopening in All Regions

Date: June 15, 2022

Attention: All Providers

Subject: Respiratory Syncytial Virus (RSV) Prophylaxis Season Reopening in All Regions

Effective Date: June 1, 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: Texas Children’s Health Plan (TCHP) would like to inform providers that the Health and Human Services Commission (HHSC) is aware of a summertime Respiratory Syncytial Virus (RSV) resurgence in multiple regions. For these reasons, as of June 1, 2022, HHSC reopened all regions to monthly administration of palivizumab (Synagis) prophylaxis to eligible members. The Texas RSV region schedule and map can be found on the Texas Health and Human Services (HHSC) Vendor Drug Program (VDP) website.

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

• A new prior authorization request is required for all members who meet the criteria for RSV prophylaxis
• 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.
• 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.
• Pharmacies are required to submit refill prior authorization requests for each subsequent dose
  • We recommend resubmitting for subsequent doses closer to the time the next dose is due. This will avoid issues with the 10-day adjudication window, or potential refill too soon rejections at the pharmacy.

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.