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Synagis (Palivizumab) Clinical Prior Authorization Forms Updated With Revised Criteria

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On November 17, 2023, the Texas Health and Human Services Commission (HHSC) updated the Synagis Standard Prior Authorization Request to include a step to check for Abrysvo vaccine administration to the client’s mother between 32 and 36 weeks of pregnancy.

Abrysvo is indicated for the active immunization of pregnant individuals at 32 through 36 weeks gestational age for the prevention of lower respiratory tract disease (LRTD) and severe LRTD caused by respiratory syncytial virus (RSV) in infants from birth through 6 months of age.

Infants whose mothers were vaccinated at the appropriate time may have full protection against RSV and should not need further prophylaxis therapy with Synagis. This immunization is time-sensitive, so if the mother was vaccinated several weeks before the RSV season began, the infant may need further treatment with either Synagis or Beyfortus to ensure protection against RSV throughout the season. 

Revisions were made to the following forms:

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