By Counterforce Health Team in Synagis (palivizumab) —

How to Get Synagis (Palivizumab) Covered by Cigna in Texas: Complete Guide to Forms, Appeals, and Approval

Answer Box: Getting Synagis Covered by Cigna in Texas

Cigna requires prior authorization for Synagis (palivizumab) via their specialty pharmacy Accredo. Submit the Cigna Synagis CCRD PA Form with clinical documentation showing high-risk criteria (prematurity, CHD, or CLD). Standard processing takes 5 business days; urgent cases can be expedited by calling (800) 882-4462. If denied, you have 180 days to file an internal appeal, followed by external review through the Texas Department of Insurance if needed. Start by downloading the PA form and gathering your child's medical records showing RSV risk factors.

Table of Contents

  1. Verify Your Plan and Coverage
  2. Required Forms and Documentation
  3. Submission Portals and Methods
  4. Specialty Pharmacy Enrollment
  5. Common Denial Reasons and Solutions
  6. Appeals Process for Texas Residents
  7. Support Contacts and Resources
  8. Keeping Information Current

Verify Your Plan and Coverage

Before starting the Synagis approval process, confirm your specific Cigna plan details. Synagis appears on Cigna's 2024 Texas 4-Tier Prescription Drug List as a Tier 4 specialty medication requiring prior authorization.

Check these key details:

  • Your plan's specialty pharmacy network (typically Accredo)
  • Current formulary tier and restrictions
  • Whether step therapy applies (trying other RSV preventions first)
  • Quantity limits per RSV season

Log into your Cigna member portal or call the customer service number on your ID card to verify coverage specifics.

Required Forms and Documentation

Primary Prior Authorization Form

The Cigna Synagis CCRD Prior Authorization Form (v011524) requires:

Patient Information:

  • Full name, Cigna ID, date of birth, address
  • Weight for dosing calculation (15 mg/kg monthly)
  • Expected injection dates through RSV season

Clinical Documentation:

  • Primary diagnosis with ICD-10 codes
  • Risk factors (prematurity, congenital heart disease, chronic lung disease)
  • Gestational age at birth
  • Current medications and medical history

Prescriber Requirements:

  • NPI number and medical license
  • Signature and date (no stamps accepted)
  • Attestation of medical necessity

RSV Season Timing Requirements

Request Period Additional Requirements
Pre-Season (before November) Justification with CDC/local health department data
Current Season (November-March) Standard documentation
Post-Season (after March) CDC virology data supporting extended dosing

All Texas counties opened for Synagis prophylaxis effective October 1, 2024, according to Texas Children's Health Plan alerts.

Submission Portals and Methods

Online Submission (Fastest)

Fax Submission

  • Standard requests: (855) 840-1678
  • Urgent requests: Call (800) 882-4462 first, then fax
  • Processing time: 5 business days for standard requests
Tip: Mark "URGENT" clearly on the form if your child needs immediate RSV protection due to high-risk status or RSV activity in your area.

Specialty Pharmacy Enrollment

Cigna partners with Accredo for Synagis distribution. Once prior authorization is approved:

Accredo Enrollment Process

  1. Prescription Transfer:
    • Fax: 877.369.3447 (include insurance cards and clinical details)
    • Phone: 877.482.5927 for verbal orders
    • E-prescribe: NCPDP 4436920
  2. Required Information:
    • Complete Synagis enrollment form
    • Insurance verification
    • Delivery preferences (home, clinic, or prescriber office)
  3. Monitoring and Refills:
    • Access MyAccredoPatients.com for order tracking
    • Monthly dosing schedule through March (end of RSV season)
    • 24/7 pharmacist support available

Delivery Options

  • Home delivery: Direct to patient address
  • Clinic administration: Shipped to prescriber's office
  • Retail pickup: Limited availability for specialty medications

Common Denial Reasons and Solutions

Denial Reason How to Address Required Documentation
Outside high-risk criteria Provide detailed medical history Cardiology/pulmonology records, birth records showing gestational age
Nirsevimab (Beyfortus) preferred Document supply shortage or contraindication CDC shortage alerts, allergy documentation
Exceeding dose/season limits Justify extended course CDC virology data, specialist recommendation
Lack of specialist documentation Obtain supporting letters Cardiology, pulmonology, or neonatology consultation

Medical Necessity Letter Checklist

Your prescriber's letter should include:

  • Specific high-risk diagnosis (prematurity <29 weeks, CHD, CLD)
  • Prior RSV hospitalizations or complications
  • Contraindications to alternative preventions
  • Weight-based dosing justification (15 mg/kg)
  • Monitoring plan and administration schedule

When working with healthcare providers to secure coverage approvals, Counterforce Health helps families and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned with each plan's specific policies and requirements.

Appeals Process for Texas Residents

Internal Appeals (Required First Step)

Level 1 Appeal:

Level 2 Appeal:

  • Automatic if Level 1 is denied
  • Independent medical review by external physicians
  • Same timeline requirements

Texas External Review Process

After exhausting internal appeals, Texas residents can request binding external review through an Independent Review Organization (IRO).

Key Requirements:

  • Must complete both internal appeal levels first
  • File within 4 months of final internal denial
  • Use TDI Form LHL009
  • No cost to patient (insurer pays IRO fees)

Expedited Review Timelines:

  • Life-threatening conditions: 5 days
  • Step therapy denials: 3 days
  • Standard specialty drug denials: 20 days
Note: Self-funded ERISA plans follow federal appeal rules, not Texas state requirements. Check your plan documents or contact HR to determine if your employer plan is self-funded.

Support Contacts and Resources

Cigna Contact Information

  • Member Services: 1-800-997-1654 (24/7)
  • Prior Authorization Urgent Line: (800) 882-4462
  • Provider Relations: Available through Cigna's state directory

Texas State Resources

  • Texas Department of Insurance Help Line: 800-252-3439
  • Office of Public Insurance Counsel: 877-611-6742
  • IRO Information Line: 866-554-4926

Manufacturer Support

  • SYNAGIS CONNECT: 866-285-8419 (billing and distribution assistance)
  • Sobi Patient Support: Available through prescriber enrollment

For families navigating complex prior authorization requirements, Counterforce Health provides comprehensive support by identifying denial reasons and developing targeted appeal strategies that address each payer's specific coverage criteria and procedural requirements.

Keeping Information Current

Insurance policies and forms change regularly. Update your information by:

Quarterly Reviews:

Annual Open Enrollment:

  • Compare Synagis coverage across available plans
  • Assess changes in prior authorization requirements
  • Evaluate specialty pharmacy networks

RSV Season Preparation:

  • Download current year's PA forms (typically updated January 1)
  • Confirm RSV season dates for your Texas county
  • Update prescriber and patient information

FAQ

How long does Cigna prior authorization take for Synagis in Texas? Standard processing is 5 business days. Urgent requests can be expedited by calling (800) 882-4462 before submitting.

What if Synagis is non-formulary on my Cigna plan? Submit a formulary exception request with clinical justification. Review timeline is 72 hours (24 hours if expedited).

Can I request expedited appeals in Texas? Yes. Expedited internal appeals are available if delays would jeopardize health. Texas external review offers 5-day decisions for life-threatening conditions.

Does step therapy apply if we tried other RSV preventions outside Texas? Document prior therapy trials with medical records. Step therapy exceptions are available if preferred drugs were ineffective or caused adverse effects.

What happens if Accredo can't fill my Synagis prescription? Contact Cigna member services to identify alternative specialty pharmacies in-network or request a temporary network exception.

From Our Advocates

We've seen families successfully overturn Synagis denials by focusing on specific high-risk criteria documentation. One effective approach involved obtaining a detailed letter from the child's cardiologist explaining why CHD status qualified for prophylaxis, combined with weight-based dosing calculations and RSV season timing justification. The key was addressing each denial point systematically rather than submitting general medical records.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Coverage policies and procedures may change.

Sources & Further Reading

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.