Both forms incorrectly indicated that a client younger than 6 months of age at the start of the RSV season with a 32- to 35-week gestational age at birth must have two of the identified risk factors in addition to a severe neuromuscular disease or significant congenital anomaly of the airway.

The forms have been corrected and the criteria have been updated to indicate the client must have either severe neuromuscular disease, significant congenital anomalies of the airway, or two of the identified risk factors.

Click the following links to view the forms:

• Texas Medicaid Palivizumab (Synagis) Prior Authorization Request Form

• CSHCN Services Program Prior Authorization Request for Palivizumab (Synagis)

For more information, call the TMHP Contact Center at 1-800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413.