Effective Date: 
9/2017

Documents

Instructions

Updated: 9/2017

 

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.

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 to the Texas Prior Authorization Call Center at 1-877-728-3927

Form Retention

There is no retention requirement.

DETAILED INSTRUCTIONS

Please see form for more information about the RSV, Synagis and dosage. Fillable portion is self-explanatory.

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