2014-15 Season Fee-For-Service Medicaid Synagis Request Form printable pdf download

Texas Medicaid/CHIP Vendor Drug Program

Fee-For-Service Medicaid Synagis® Request Form

2014-15 Season

About

The start of the respiratory syncytial virus (RSV) season varies based on a client’s county of residence. See

county table at

The treating provider identifies a client enrolled in fee-for-service Medicaid with conditions that may require

Respiratory Syncytial Virus (RSV) prophylaxis with Synagis. If the client is enrolled in Medicaid Managed Care

then the provider must contact the health plan to obtain the plan’s instruction for obtaining Synagis. The provider

should utilize the Prescriber Assistance Chart at

to obtain plan

contact information.

Initial Dosage

The provider or provider's agent will send a prescription for Synagis with supporting clinical information on the

Fee-For-Service Medicaid Synagis Request Form to a Medicaid-enrolled pharmacy. Prior authorization is

required for all clients. It is recommended that the pharmacy be one of the Synagis participating pharmacies

noted at

The pharmacy faxes the completed Fee-For-Service Medicaid Synagis Request Form to the

Texas Prior

Authorization Call Center

at 1-866-617-8864.

If the information submitted does not demonstrate medical necessity then the request is denied and both the

pharmacy and provider are notified of the denial of prior authorization request.

If the information submitted does demonstrate medical necessity, the request is approved. Both the pharmacy and

provider are notified of the approval. If the prior authorization is approved, the dispensing pharmacy fills the

prescription and ships an individual dose of the medication, in the name of the Medicaid patient, directly to the

provider. An initiation packet also is mailed by the dispensing pharmacy to the client's family, informing them of

Synagis and its effects.

The physician or provider under the direct supervision of the physician administers the Synagis. The injection

provider may only bill for an injection administration fee and any medically necessary office-based evaluation

and management services provided at the time of injection. The pharmacy provider is reimbursed for the drug and

dispensing fees.

Subsequent Dosage

For each monthly dose, the pharmacy receives an approval letter from

Texas Prior Authorization Call

Center,

pharmacy must complete the table provided on the approval letter no sooner than one week before billing for the

subsequent dose. The pharmacy must contact the prescriber to:

•

Verify that the client has not experienced a breakthrough RSV hospitalization.

•

Obtain updated patient's weight.

•

Verify that the patient was administered all previously dispensed Synagis prescriptions.

•

Pharmacies should maintain a log of the information obtained from the injecting provider.

Contact

Pharmacies with questions about the Fee-For-Service Medicaid Synagis Request Form should call the

Texas

Prior Authorization Call Center

at 1-877-728-3927.

Rev. 09/2014

Page 1 of 3

File: vdp_dur_syngfv

2014-15 Season Fee-For-Service Medicaid Synagis Request Form

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