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Criteria Changes for Subsequent Dosing of Palivizumab (Synagis) for Upcoming Respiratory Syncytial Virus Season

Last updated on 9/28/2022

Beginning with the fall traditional respiratory syncytial virus (RSV) season, the Texas Health and Human Services Commission (HHSC) will implement revised approval criteria for palivizumab (Synagis) subsequent dosing (renewals). Providers will no longer be required to check a client’s weight or confirm the administration of a previous dosing.

The traditional RSV season start date is not yet determined and is pending recommendation from the Texas Pediatric Society's RSV Task Force in coordination with HHSC.

HHSC will revise the Synagis Standard Prior Authorization Addenda for Medicaid (HHS Form 1321) and the Children with Special Health Care Needs (CSHCN) Services Program (HHS Form 1325) and make them available before the beginning of the RSV season.

The Synagis clinical prior authorization criteria and policies are mandatory for managed care. The Pharmacy Clinical Prior Authorization Assistance Chart indicates which prior authorizations each MCO uses. The chart is updated quarterly. Providers can also contact the MCO for the MCO's list of clinical prior authorizations.

Contact vdp-formulary@hhsc.state.tx.us with comments or any questions.