Texas Medicaid: Respiratory syncytial virus season and Synagis prior authorization

The Texas Pediatric Society (TPS) respiratory syncytial virus (RSV) task force tracked the most recent trends of positive tests for RSV in all regions. We’ll authorize Synagis for the following regions according to Texas Health and Human Services (HHSC) guidelines:

Start date	End date	Region
Oct. 1, 2025	Feb. 28, 2026	5, 6
Oct. 15, 2025	March 13, 2026	7, 11
Nov. 1, 2025	March 31, 2026	3, 4, 8
Nov. 15, 2025	April 17, 2026	1, 2, 9, 10

HHSC based this season's staggered schedule on the patient's county of residence at the start of the season. UnitedHealthcare Community Plan of Texas will follow the same schedule for their regions.

What you need to do

You’ll need to provide Synagis to infants meeting criteria as described by the American Academy of Pediatrics (AAP).

We’ll allow prescribers to use the Texas Department of Insurance (TDI) Texas standard prior authorization form for prescription drug benefits for Synagis prior authorization requests.

We won’t refuse the submission of the TDI form, but we may request additional details through an addendum form or a phone call. We may request you to submit Form 1321 with the TDI standard prior authorization form.

Prior authorization criteria

HHSC updated the following prior authorization criteria on the form to reflect recommendations from the HHSC Office of Medical Director and the AAP Red Book:

Drug name/strength	National drug code
Synagis 100 MG/1 ml Vial	66658023101
Synagis 50 MG/0.5 ml Vial	66658023001

Our medical directors may end the RSV season for our members by service area if we determine the local antigen positivity testing has dropped below 10% for 2 consecutive weeks or the local polymerase chain reaction (PRC) positivity has dropped below 3% for 2 consecutive weeks.

HHSC will continue to work with the TPS RSV task force to determine if a change to the RSV prophylaxis schedule is needed for any region and will provide subsequent communication.