The Children with Special Health Care Needs (CSHCN) Services Program covers Synagis to treat high-risk patients with Human Respiratory Syncytial Virus (RSV).
When to Prepare
The prescribing provider or provider assistant sends a prescription for Synagis with refills and supporting information to the CSHCN-enrolled pharmacy.
Providers must submit form 1325 and Texas Standard Prior Authorization Request Form for Prescription Drug Benefits.
Providers should 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.
Refer comments or questions about this form to the CSHCN Services Program at 800-252-8023.