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

Last updated on 5/25/2022

The Texas Health and Human Services Commission (HHSC) will take necessary action to prevent the further spread of RSV by reopening all regions to monthly administration of palivizumab (Synagis) prophylaxis to eligible Medicaid managed care organizations (MCOs) members beginning June 1, 2022. HHSC is aware of a summertime RSV resurgence in multiple regions across the state. In response to this RSV activity and consultation with medical experts from across the state, providers may start monthly palivizumab (Synagis) prophylaxis treatment for all eligible members.

Because of higher RSV positivity rates in regions 3 and 6, HHSC has encouraged MCOs to allow access to palivizumab (Synagis) earlier than June 1, 2022 if administratively possible. Contact the MCO for further information.

HHSC requires a new prior authorization request for all members who meet the criteria for RSV prophylaxis with palivizumab (Synagis). Per HHSC policy and RSV guidelines, members should receive one dose per month, up to five doses per treatment course.

MCO medical directors can end the RSV season for their given service area if data is submitted to HHSC to indicate that the local polymerase chain reaction test virology has dropped below 3% positivity for two consecutive weeks. It is not possible to anticipate how this summertime RSV activity will impact the traditional 2022-23 RSV season. HHSC will continue to monitor all regions and provide further guidance as the RSV season progresses.

Medicaid Managed Care and CHIP

Providers must contact the member’s MCO for the MCO’s prior authorization forms and instructions.

Medicaid Fee-for-Service

Providers must use the following two prior authorization forms:

Addendum forms are used alongside the TDI form to provide the necessary clinical information specific to palivizumab (Synagis). Complete both forms and send them to the dispensing pharmacy to obtain prior authorization. Pharmacy staff will fax the forms to the Texas Prior Authorization Call Center for processing. Providers can call the Texas Prior Authorization Center at 877-728-3927 for questions or assistance with the form.

Children with Special Health Care Needs (CSHCN) Services Program

Providers must use the following two prior authorization forms:

Contact the CSHCN Services Program at 800-252-8023 for questions or assistance with the form.

Email comments or questions to vdp-formulary@hhsc.state.tx.us.