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