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

The Texas Medicaid Palivizumab (Synagis) Standard Prior Authorization Request form, issued by the Texas Health and Human Services (HHS), is used to request approval for Synagis treatment in infants and children at high risk of severe illnesses from Respiratory Syncytial Virus (RSV). The form is required monthly for patients enrolled in Medicaid fee-for-service (FFS) and provides instructions for prior authorization processes.

This form is designed for healthcare providers, pharmacies, and managed care organizations to facilitate the approval process. It outlines the necessary information and steps to request Synagis treatment, including the submission of supporting clinical information and the notification of approval or denial. The form also includes guidance on subsequent dosages and the requirements for continued treatment.

The Texas Prior Authorization Call Center provides support and assistance throughout the prior authorization process. Prescribing providers may request a reconsideration of a denied prior authorization by completing and faxing the reconsideration request, HHS Form 1322. The form is an essential tool in ensuring timely access to Synagis treatment for patients who meet the criteria for approval.