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Prior Authorization Guidelines for the Synagis® 2016-2017 Season

Date: 09/30/16

Superior HealthPlan will follow the Texas Vendor Drug Program (VDP) Syangis® prior authorization guidelines for the 2016-2017 Respiratory Syncytial Virus (RSV) season. The criteria has not changed from the previous 2015-2016 season. 

Please note, the 2016-17 season will follow a four-part roll-out schedule beginning October 1st, then October 15th, November 1st and finally November 15th 2016. Providers are strongly encouraged to follow the schedule closely when submitting for prior authorizations. The start dates are region/county specific. Please refer to the following link for your county’s exact region, start date and season end date: Schedule for Synagis® by County

Helpful Synagis Prior Authorization Information:

  • If a member meets criteria, up to five total doses may be authorized for the season.
  • Please include any previous NICU doses with the prior authorization submission.
  • As a reminder, once authorized, a patient who has had RSV this season should not continue to receive Syangis®.

For more information clinical edit criteria and prior authorizations, please review Synagis® Clinical Criteria.

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®. Please note your preference for specialty pharmacy from these two options on the prior authorization form: Synagis® Prior Authorization Form

The specialty pharmacy will be responsible for the delivery of the injectable product and the overall coordination of the drug distribution process. All injectable products will be billed directly to Superior by AcariaHealth or CVS/caremark and shipped to the provider’s office. Administration charges for the injection should be billed directly to Superior on a (HCFA) CMS 1500 claim form using CPT code 96372. Providers can also bill for an appropriate office visit for each administration of the drug. As a reminder, 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.

Superior’s Pharmacy department will perform all prior authorizations for Synagis®. To submit your request, fax the completed authorization form to 1-866-683-5631.

For questions, contact the Superior Pharmacy department at 1-800-218-7453, ext. 22080.