Form 1325, Synagis Prior Authorization Addendum (CSHCN)

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Reader on your desktop system. Click here for instructions on accessing your form.
Effective Date
12/2021
Document
1325.pdf (127.59 KB)

Instructions

Updated: 12/2021

Purpose

The Children with Special Health Care Needs (CSHCN) Services Program covers Synagis to treat high-risk patients with Human Respiratory Syncytial Virus (RSV). 

Procedure

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 (PDF).

Transmittal

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. 

Questions

Refer comments or questions about this form to the CSHCN Services Program at 800-252-8023.