Synagis Prior Authorization Guidelines for the 2015-2016 Season

Date: 10/01/15

Superior HealthPlan (Superior) will follow the guidance of the Texas Vendor Drug Program (VDP) in regards to Syangis Prior Authorization (PA) guidelines for the 2015-2016 Synagis® season.

The Texas Vendor Drug Program county schedule will be followed for all prior authorization approvals. Please note, most areas of the state will begin October 1, 2015 and end on February 29, 2016. Counties in the west will begin November 1, 2015 and end on March 31, 2016.

All prior authorizations will be performed by the Superior Pharmacy department.

Synagis information and materials can be found on the Superior website:

Synagis Prior Authorization Form
Synagis Notification Letter
Schedule for Synagis by County 
Synagis Clinical Criteria

Synagis® is available through a limited distribution network as established by the manufacturer. AcariaHealth and CVS Caremark are the two specialty pharmacy providers contracted with Superior HealthPlan for Synagis®. Please provide the specialty pharmacy of choice on your prior authorization request. When submitting the request, please include the NICU discharge summary to expedite the review process.

The specialty pharmacy will be responsible for the delivery of the injectable product and the overall coordination of the drug distribution process. All injectable products will be billed directly to Superior by AcariaHealth or CVS Caremark and shipped to the provider’s office.

For questions, please contact the Superior Pharmacy department at 1-800-218-7453, ext. 22080.