Form 1321, Synagis Standard Prior Authorization Addendum (Medicaid)

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Documents

Effective Date: 6/2022

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

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

Transmittal

Staff send the form to the Medicaid-enrolled pharmacy, who then forwards the completed form by fax to the Texas Prior Authorization Call Center at 1-866-469-8590. Prescribing providers with questions should call the Texas Prior Authorization Call Center at 877-728-3927.

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.