TX HHS Form 1321. Texas Medicaid Palivizumab (Synagis) Standard Prior Authorization Request

The Texas Medicaid Palivizumab (Synagis) Standard Prior Authorization Request Form (HHS Form 1321) is a crucial tool for healthcare providers to obtain prior authorization for Synagis treatment in infants and children at high risk of severe RSV infections. This form helps solve the problem of ensuring that patients receive necessary medication while streamlining the approval process.

This form is typically used by prescribing providers, including physicians and other qualified healthcare professionals, who need to request prior authorization for Synagis treatment on behalf of their patients enrolled in Medicaid fee-for-service (FFS) or managed care programs. The form requires specific information, such as patient demographics, medical history, and RSV infection risk factors.

The Texas Prior Authorization Call Center plays a key role in the approval process, notifying pharmacies and providers if approved. Key features of this form include the requirement for monthly prior authorization requests, the need to verify clinically appropriate indications for continuing treatment, and the responsibility of pharmacies to maintain a log of total doses per season. Providers with questions can contact the Texas Prior Authorization Call Center at 877-728-3927.

• This form is used for patients enrolled in Medicaid fee-for-service (FFS) or managed care programs.
• Prior authorization is required monthly for patients enrolled in FFS.
• The treating provider should contact the patient's MCO for instructions on prior authorization processes for managed care patients.