Form 1325, Synagis Prior Authorization Addendum (CSHCN)

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Effective Date: 4/2024


Updated: 10/2022


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.