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43.4.2.4 Obtaining Palivizumab
Providers have two options for obtaining palivizumab for Medicaid clients in fee-for-service and PCCM: Providers may purchase and bill for palivizumab; or they may obtain the drug through the VDP.
Note: For Medicaid Managed Care clients, providers must contact the client's HMO.
Option 1-Traditional reimbursement for palivizumab:
1) |
The treating provider identifies a Medicaid-enrolled client with indications for RSV prophylaxis with palivizumab. |
2) |
The provider purchases palivizumab for administration to the client in office. |
4) |
The injection provider bills for the drug, an injection administration fee, and any medically necessary office-based E/M service provided at time of injection. |
5) |
The provider is reimbursed through the Texas Medicaid Program claims payment system. |
Option 2-Obtaining palivizumab through the VDP
1) |
The treating provider identifies a Medicaid-enrolled client with indications for RSV prophylaxis with palivizumab. |
2) |
The provider obtains palivizumab through the VDP. |
The provider or provider's agent sends a prescription for palivizumab with supporting clinical information on the Texas Medicaid Vendor Drug Program Palivizumab (Synagis) Prescription Form to a Texas Medicaid-enrolled pharmacy that is a member of the Synagis Distribution Network. The administering provider does not purchase the drug.
Refer to: HHSC's Vendor Drug Program Active Pharmacy Search page (www.hhsc.state.tx.us/hcf/vdp
/dw/PharmacySearch.html) to search for participating pharmacies.
4) |
The pharmacy contacts VDP's Prior Authorization Call Center. Prior authorization is required for all clients. |
5) |
If the information submitted does not demonstrate medical necessity the request is denied. Both the pharmacy and provider are notified of the denial. |
6) |
If the information submitted demonstrates medical necessity, the request is approved and both pharmacy and provider are notified. |
7) |
The selected pharmacy fills the prescription and overnight ships an individual dose of the medication, in the name of the Medicaid client, directly to the provider. An initiation packet also is mailed to the client's family, informing them of RSV and palivizumab's benefits and side effects. |
8) |
The treating provider administers the palivizumab injection to the Medicaid client in the office setting. |
9) |
The injection provider bills for an injection administration fee and any medically necessary office-based E/M service provided at time of injection. The provider does not bill the Texas Medicaid Program for the drug. |
10) |
The pharmacy contacts the provider each month after initial injection to obtain updated client information to ensure the proper amount for the next dose.
The following client demographic information is required: |
• The client's date of birth.
•The client's age in months, as of October 1, 2006.
•The client's estimated gestational age (in weeks) at birth.
•The client's body weight (in pounds or kilograms).
•The monthly dose required.
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