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Respiratory Syncytial Virus (RSV) and Synagis Authorization During Summer and Winter 2021-2022

Date: 09/15/21

As a result of the recent summertime resurgence in Respiratory Syncytial Virus (RSV) activity, Texas Health and Human Services (HHS) began opening The Texas Department of State Health Services (DSHS) regions gradually from June 21 through July 23, 2021. With the traditional 2021-22 RSV season beginning on October 1, 2021, all Texas DSHS regions will remain open and all Superior Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP members who meet prior authorization criteria will be eligible for up to 5 monthly doses of Synagis®.

If a child received doses of Synagis® from June 21 through September 30, 2021, they will require reassessment as of October 1, 2021.  Since the traditional 2021-22 RSV season will begin a new season beginning October 1, 2021, children who may require additional doses of Synagis® will require completion of a new prior authorization process for possible additional doses.

At this time, it is not possible to anticipate if RSV activity will continue to spread equally in all regions or if it will increase to levels of activity typically seen during the fall and winter months. As new developments arise, it may be necessary to close certain regions based on the latest RSV activity reports. HHS will continue to monitor RSV activity, and engage with DSHS and practicing physicians to provide further guidance to all Medicaid MCOs as the RSV season progresses. To see the full schedule, please visit: Texas HHS RSV Season Schedule.

DSHS monitors RSV activity year-round in its 11 Public Health regions and collects data which is followed by HHS and the RSV Taskforce of practicing physicians from around the state. To access this data, please visit: Texas DSHS RSV Data

Helpful Synagis® Prior Authorization Information

Superior HealthPlan follows the Texas Vendor Drug Program (VDP) clinical prior authorization criteria. To access the current clinical criteria, please see Synagis Clinical Criteria on Superior’s Clinical Prior Authorization webpage.

Please note:

  • Providers must include any previous Neonatal Intensive Care Unit (NICU) doses with the prior authorization submission.
  • Once authorized, a member who has been diagnosed with RSV this season should not continue to receive refills of Synagis®.
  • The specialty pharmacy will need a prescription sent to the pharmacy directly by the medical office for any member with approved prior authorization.

Submitting Synagis® Prior Authorization Requests

Synagis® is available through a limited distribution network as established by the manufacturer. AcariaHealth and CVS/Caremark are the two specialty pharmacy providers contracted with Superior for Synagis®. See below for specific information when submitting prior authorization requests:

  • Providers should use the Synagis® Season – Prior Authorization Form.
    • Be sure to list your preference for specialty pharmacy (AcariaHealth or CVS/Caremark) on the form, under Section I – Dispensing Pharmacy Information.
    • Providers may also use/submit the standard Texas Department of Insurance (TDI) Prior Authorization Request Form.
      • If this specific form is used/submitted, they will also be required to submit the Synagis® Season – Addendum Prior Authorization Form.
    • The forms mentioned above can be found on Superior’s Provider Forms webpage.
  • Superior’s Pharmacy department will perform all prior authorizations for Synagis®. To submit your request, fax the completed authorization form (linked above) to 1-866-683-5631.
  • Once approved, the requesting provider’s medical office can then submit a prescription directly to the specialty pharmacy.
  • Automated refills are not permissible per the Texas Medicaid Provider Procedures Manual. Providers will need to request or authorize the refill from the pharmacy each time it is needed. If the member is diagnosed with RSV this season, the office should not continue to request refills of Synagis® for that member.

For questions, please contact Superior’s Pharmacy Department at 1-800-218-7453, ext. 22272.