2025–26 RSV Season and Synagis Prior Authorization for All State Health Service Regions

Date: September 23, 2025

Attention: All Providers

Subject: 2025–26 RSV Season and Synagis Prior Authorization for All State Health Service Regions

Effective Date: October 1, 2025

Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that effective October 1, 2025, the Texas Health and Human Services (HHSC) will open all counties in State Health Service to Palivizumab (Synagis) prophylaxis for 2025-26 Fall/Winter Respiratory Syncytial Virus (RSV) season. Refer to the season schedule for each region's start and end dates.

How this impacts providers: HHSC will accept fee-for-service (FFS) prior authorization requests by fax and as early as September 22, 2025.

Prescribing providers must prescribe Synagis to infants meeting the criteria as described on the American Academy of Pediatrics website. 

• Pharmacy Benefit Access

Similar to STAR and STAR KIDS, Synagis for CHIP members will be available through the pharmacy benefit. Prior authorization (PA) criteria will be the same for all members.

• Initial PA Request Required

Providers must submit a new PA request for all members who meet criteria for RSV prophylaxis. Only one initial request is needed per treatment course (up to five doses).

• Dose Approval Details

Approvals will be granted for one monthly dose at a time, with a 10-day window for pharmacy adjudication. Providers should retain Synagis vials until administration to avoid missed doses.

• Required Forms for PA Submission

Providers must submit both the Texas Department of Insurance (TDI) Synagis PA Form and the TCHP Standard PA Request Form.

• Forms are available on the Navitus page.
• Texas HHSC has also created the Synagis Standard PA Addendum (HHS Form 1321) to accompany the TDI form.
• No Refill PA Required

Pharmacies are not required to submit refill PA requests for subsequent doses.

• Hospitalization Note

Members hospitalized for RSV during the season may be denied further Synagis refills.

• Preferred Pharmacies

Acaria Health Pharmacy and Lumicera Specialty Pharmacy are the preferred options for all providers.

2025-26 Synagis Prior Authorization Schedule:

Updated as of September 11, 2025. Refer to HHSC’s website for the most up-to-date information.

Providers can find their region using the interactive region map (PDF)and selecting the buttons marked HHS regions and county names.

Table 1: Region Dates

Next steps for providers: Refer to the 2025-2026 RSV season schedule for information regarding start and end dates for all regions. Providers should continue to follow American Academy of Pediatrics guidelines when prescribing and should share this communication with their staff.

Resources:

• Texas DSHS Infectious Disease Control: Respiratory Syncytial Virus
• Refer to the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook of the Texas Medicaid Provider Procedures Manual (TMPPM)
• Centers for Disease Control and Prevention: Respiratory Syncytial Virus Infection (RSV)

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

For access to all provider alerts,log into: 
www.texaschildrenshealthplan.org/provideralerts.