2020-21 RSV Season and Synagis (palivizumab)

Attention: All ProvidersEffective Date: September 24, 2020

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action:Respiratory Syncytial Virus (RSV) season is here! The Texas RSV region schedule and map can be found on the Texas Health and Human Services (HHSC) Vendor Drug Program (VDP) website.  Texas Children’s Health Plan (TCHP) authorizes palivizumab based on criteria determined by the American Academy of Pediatrics (AAP) recommendations. Clinical recommendations remain unchanged from 2014 and can be found here. 

There are several changes to the 2020-2021 season. Please review these changes carefully.

1. Similar to STAR and STAR KIDS, Synagis for CHIP members will only be available through the pharmacy benefit. The prior authorization criteria will be the same for all members.  
2. Providers may submit prior authorizations as early as September 1, but pharmacies will not be able to process before September 24.
3. TCHP will offer a third TCH Pharmacy for internal TCH providers. In addition to the Centers Pharmacies (Greenspoint and Southwest), TCH Main Campus Pharmacy is now an option. Lumicera Specialty Pharmacy, and Walmart Specialty Pharmacy will be available for all others.
   • PA forms specific to the TCH Pharmacies (Main Campus, Greenspoint and Southwest) can be provided by the pharmacy department.
4. BOTH the Texas Standard Prior Authorization request form AND the Synagis PA request form must be submitted with all initial Synagis requests. Failure to include both forms will result in the request being rejected as incomplete.
   • The Texas Standard PA form can be found here:https://txstarchip.navitus.com/pdf-documents/pa-forms/texas-standard-prior-authorization-request-form.aspx
   • TCHP’s prior authorization forms can be found on the Navitus website. 
5. Approvals will be limited to one (1) monthly dose at a time. The approval will only allow for a 10-day window for pharmacy adjudication.  The provider should hold the member’s Synagis vial(s) until that dose can be administered to prevent potential for missed doses.
   • We recommend resubmitting for subsequent doses closer to the time the next dose is due. This will avoid issues with the 10-day adjudication window, or potential refill too soon rejections at the pharmacy.
6. Up to five (5) monthly doses total may be authorized throughout RV season.  Each subsequent dose after the initial dose must be requested with a prior authorization form completed by the dispensing pharmacy. 
   • The dispensing pharmacy is required to obtain confirmation of all administered doses from the provider, including any inpatient doses that may have been given.
   • Subsequent PA forms can be found here: https://txstarchip.navitus.com/pdf-documents/other/synagis-renewal_tx-mcaid_090120.aspx

Next steps for providers: Please review these changes carefully. Providers should continue to follow American Academy of Pediatrics guidelines when prescribing. Off-season requests, or extended therapy requests, will need further case by case review by TCHP.

If you have any questions, please email the Pharmacy department at: tchppharmacy@texaschildrens.org.

For access to all provider alerts,log into: www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.