Blue Cross and Blue Shield of Texas (BCBSTX) would like to take this opportunity to provide information regarding the RSV Prophylaxis program.

• BCBSTX will review all requests for Synagis for BCBSTX members. The specific medical criteria for coverage may be found in our medical policy guideline for "Respiratory Syncytial Virus (RSV) Immunoprophylaxis" which is available online at http://medicalpolicy.hcsc.net/medicalpolicy/home?corpEntCd=TX1&externalTest=true.  Note: Once you read and agree to the terms and conditions, search for medical policy number RX504.009 and then click on "Go".
• A predetermination/authorization of medical records expedites the claims process by reducing post payment audits, record requests, and/or medical necessity denials by determining before the services are rendered that the medical policy criteria are met.
• For out-of-state members you will need to contact the member's Home Plan for eligibility and benefit information. The phone number will be on the back of the member's ID card.
• If approved, the predetermination will cover all monthly injections for that patient for the current season beginning October of the current year and ending in February of the following year. No additional reviews will be required for that season.

BCBSTX Health Plan Predetermination/Authorization Process 

• Complete the BCBSTX Synagis Request Form in its entirety. Two types of forms are available on the BCBSTX Provider Web site.
• Press “submit” for the online version of the form or fax the completed  interactive version of the Synagis Request Form to Allan J. Chernov, M.D. (Medical Director, Health Care Quality & Policy) at  (972) 766-5559.
• If you submit the completed form by mail or fax, BCBSTX will notify you of the review outcome by mail; if you use the online option, you will be notified by e-mail.
• Please note that there will be no predetermination/authorization number provided for Synagis. (If the patient needs a referral number to a specialty physician due to contract requirements, this referral number is not part of the Synagis predetermination/authorization procedure.)

Synagis Distribution
BCBSTX has selected Triessent™ as the BCBSTX participating provider for Synagis*.  This pharmacy will coordinate the delivery of each dose of Synagis with the physician's office to ensure appropriate Synagis dosing of each patient.  Also, ordering Synagis through Triessent™ allows the physician's office to avoid "buying and billing" for the medication.

*Pending regulatory approval

Ordering Synagis
STEP 1 – BCBSTX Health Plan Predetermination/Authorization Process

• Complete the BCBSTX Synagis Request Form in its entirety and submit via fax or online option.

STEP 2 – Ordering Process for Triessent™

• Fax the Synagis Request Form, along with written authorization from BCBSTX.

If you obtain Synagis from a source other than Triessent™, file the claim directly to BCBSTX.

Payment of claims will depend on continued eligibility of the patient. Any copays, deductibles, and coinsurance will be the responsibility of the member. 

Please address any additional questions such as fee schedules, preferred vendors, referrals, etc., with Provider Customer Service or your local Professional Provider Network office, as appropriate.

updated 8-2008