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2013/2014 Synagis Predetermination Process

August 23, 2013

The Respiratory Syncytial Virus (RSV) season is upon us. Blue Cross and Blue Shield of Texas (BCBSTX) would like to take this opportunity to review the predetermination process for the RSV Prophylaxis program.

STEP 1 – BCBSTX Health Plan Predetermination/Authorization Process

  • Complete the BCBSTX Synagis Request Form. Two types of forms (online and hard-copy) are posted.
  • Submit the completed online version of the form; or fax the completed hard-copy version to Allan J. Chernov, M.D. (Medical Director, Health Care Quality & Policy) at 972-766-5559.


STEP 2 – Ordering Process for Prime Specialty Pharmacy

  • Fax the Synagis Request Form, along with written authorization from BCBSTX, to Prime Specialty Pharmacy at: 877-828-3939.


  If the request form is incomplete, Prime Specialty Pharmacy will not process the order. The request form will be returned to the prescribing physician to supply the missing information.