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On Feb. 21, 2024, Change Healthcare experienced a cyber security incident. Any individuals impacted by this incident will receive a letter in the mail. Learn more about this from Change Healthcare, or reach out to the contact center at 1-866-262-5342.

On Feb. 21, 2024, Change Healthcare experienced a cyber security incident. Any individuals impacted by this incident will receive a letter in the mail. Learn more about this from Change Healthcare, or reach out to the contact center at 1-866-262-5342.

Respiratory Syncytial Virus (RSV) Prophylaxis Fall/Winter Traditional Season Changes

Date: 10/19/22

On October 17, 2022, Texas Health and Human Services Commission (HHSC) opened all eleven Texas Public Health Service regions to Palivizumab (Synagis®) prophylaxis for an anticipated traditional 2022 – 2023 Fall/Winter Respiratory Syncytial Virus (RSV) season. HHSC, in collaboration with the Texas Pediatric Society’s RSV Task Force, is making these changes based on RSV testing data indicating a general increase in viral activity throughout most regions of the state.

For clinical prior authorization purposes, the 2022-23 Fall/Winter traditional RSV season is considered a new season beginning October 17, separate from the 2022 summer season. Therefore, all open authorizations approved during the 2022 summer season were ended effective October 16, 2022.For information regarding start and end dates for all regions, please refer to the HHS RSV Season Schedule.

The start of a new RSV season is an important consideration for HHSC's prior authorization policy regarding the approval of up to five monthly shots of Palivizumab (Synagis) per season. Texas Medicaid members who still meet the Palivizumab (Synagis) prior authorization approval criteria at the beginning of the new season on October 17, will be eligible to receive an additional five monthly shots (if necessary).

The anticipated duration of the traditional fall/winter season is unknown, and it may be necessary to close certain regions based on the RSV activity reports. HHSC will continue to monitor RSV testing data and coordinate with the Texas Pediatric Society's RSV Task Force for future regional changes. HHSC will continue monitoring RSV activity to provide further guidance and communicate any regional changes as this information becomes available.

Helpful Synagis® Prior Authorization Information

Superior follows the Texas Vendor Drug Program (VDP) clinical prior authorization criteria for Superior HealthPlan Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP. To access the current clinical criteria, please see Synagis Clinical Criteria on Superior’s Clinical Prior Authorization webpage.

Please note:

  • Providers must include any previous Neonatal Intensive Care Unit (NICU) doses with the prior authorization submission.
  • Once authorized, a member who has been hospitalized with RSV this season should not continue to receive refills of Synagis®.
  • The specialty pharmacy will need a prescription sent to the pharmacy directly by the medical office for any member with approved prior authorization.

Submitting Synagis® Prior Authorization Requests

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®. See below for specific information when submitting prior authorization requests:

  • Providers should use the Synagis® Season – Prior Authorization Form (PDF)
  • Be sure to list your preference for specialty pharmacy (AcariaHealth or CVS/Caremark) on the form, under Section I – Dispensing Pharmacy Information.
  • Superior’s Pharmacy Department will perform all prior authorizations for Synagis®. To submit your request, fax the completed authorization form (linked above) to 1-866-683-5631.
  • Once approved, the requesting provider’s medical office can then submit a prescription directly to the specialty pharmacy.

Synagis® Delivery, Billing and Refills

  • 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 the specialty pharmacy and shipped to the provider’s office. Administration charges for the injection should be billed directly to Superior, using Current Procedural Terminology (CPT) code 96372, on the Health Care Financing Administration (HCFA) CMS 1500 Claim Form (PDF). Providers can also bill for an appropriate office visit for each administration of the drug.
  • Automated refills are not permissible per the Texas Medicaid Provider Procedures Manual (TMPPM). Providers will need to request or authorize the refill from the pharmacy each time it is needed.

For any questions, please contact Superior’s Pharmacy Department at 1-800-218-7453, ext. 22272.