Synagis (palivizumab) Clinical Prior Authorization Forms Updated with Revised Abrysvo Criteria

Date: December 4, 2023

Attention: All Providers

Effective date: November 17, 2023

Call to action: On November 17, 2023, Health and Human Services Commission (HHSC) updated the Synagis Standard Prior Authorization Request (HHS Form 1321) to include a step to check for Abrysvo vaccine administration to the client’s mother during 32 to 36 weeks of pregnancy.

How this impacts providers: Additional information on Abrysvo Vaccine include the following:

• Abrysvo is indicated for active immunization of pregnant individuals at 32 through 36 weeks gestational age for the prevention of lower respiratory tract disease (LRTD) and severe LRTD caused by respiratory syncytial virus (RSV) in infants from birth through 6 months.
• Infants whose mothers were vaccinated at the appropriate time may have full protection against RSV and should not need further prophylaxis therapy with Synagis.
• Since this immunization is time-sensitive, if the mother was vaccinated several weeks before the RSV season, the infant may need further treatment with either Synagis or Beyfortus to ensure protection against RSV throughout the entire season.

Next step for Providers: Providers should share this communication with their staff.

Resource: link to HHS form 1321 hhs.texas.gov/regulations/forms/1000-1999/form-1321-synagis-standard-prior-authorization-addendum-medicaid

If you have any questions, please email Provider Relations at: providerrelations@texaschildrens.org.

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