Form 1321, Synagis Standard Prior Authorization Addendum (Medicaid)

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Documents

Effective Date: 11/2023

Instructions

Updated: 11/2022

PURPOSE

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

PROCEDURE

When to Prepare

The prescribing provider or provider assistant sends a prescription for Synagis with refills and supporting information to the Medicaid-enrolled pharmacy.

Providers must submit form 1321 and the Texas Standard Prior Authorization Request Form for Prescription Drug Benefits.

Transmittal

Providers should send the form to the Medicaid-enrolled pharmacy, which then forwards the completed form by fax to the Texas Prior Authorization Call Center at 866-469-8590.

Prescribing providers with questions should call the Texas Prior Authorization Call Center at 877-728-3927.