To request the drug Synagis to treat Human Respiratory Syncytial Virus (RSV) for high-risk patients.
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.
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 866-469-8590. Prescribing providers with questions should call to the Texas Prior Authorization Call Center at 877-728-3927
There is no retention requirement.
Please see form for more information about the RSV, Synagis and dosage. Fillable portion is self-explanatory.