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Effective Date: 
11/2020

Documents

 

Instructions

Updated: 8/2019

 

PURPOSE

To request the drug Synagis to treat Human Respiratory Syncytial Virus (RSV) for high risk patients.

 

PROCEDURE

When to Prepare

To request prior authorization for patients who are enrolled in the Children with Special Health Care Needs (CSHCN) service program. The prescribing provider or provider assistant sends a prescription for Synagis with refills and supporting information to the CSHCN-enrolled pharmacy.

The addendum must accompany the Texas Department of Insurance Standard Prior Authorization Form (PDF).

Transmittal

Staff send the form to the CSHCN-enrolled pharmacy, who then forwards the completed form by fax to the CSHCN Services Program at 512-776-7238. Prescribing providers with questions should call the CSHCN Services Program at 800-252-8023.

Form Retention

There is no retention requirement.

 

DETAILED INSTRUCTIONS

Please see the form for more information about the RSV, Synagis and dosage. Fillable portion is self-explanatory.