Revised Criteria for Synagis Prior Authorization Forms


On November 17, 2023, Texas Health and Human Services Commission (HHSC) updated the Synagis Standard Prior Authorization Request to include a step to check for Abyrsvo vaccine administered to mothers during 32 to 36 weeks of pregnancy.


  • Abrysvo is indicated for active immunization of pregnant women at 32 through 36 weeks gestational age for the prevention of lower respiratory tract disease (LRTD) and severe LRTD caused by respiratory syncytial virus (RSV) in infants from birth through 6 months.
  • Infants whose mothers were vaccinated at the appropriate time may have full protection against RSV and should not need further prophylaxis therapy with Synagis, and BCBSTX should deny the prior authorization request.
  • Since this immunization is time-sensitive, if the mother was vaccinated several weeks before the RSV season, the infant may need further treatment with either Synagis or Beygorus to ensure protection against RSV throughout the entire season.

Prior Authorization Forms

Blue Cross and Blue Shield of Texas (BCBSTX) authorization forms are located on our Utilization Management page. Below are the 2 required documents to submit for processing.

Providers, for questions or additional information, please: