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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Appendix B: Vendor Drug Program : B.3 Palivizumab (Synagis) Available Through the VDP : B.3.1 Participating Palivizumab Distribution Pharmacies

B.3.1
For a list of participating pharmacies, refer to the HHSC Vendor Drug website at www.txvendordrug.com.
Note:
Palivizumab forms are updated every year. Providers must use the most current version of the forms to submit prior authorization requests.

The Texas Medicaid Palivizumab (Synagis) Prior Authorization Request Form is required if the prescribing provider purchases the drug and bills TMHP.

The Texas Medicaid Vendor Drug Program for Outpatient Pharmacies Synagis (Palivizumab) Prior Authorization Request & Prescription Form for 2011 is required when the prescribing provider obtains the drug through VDP.
Refer to:
Subsection 8.2.54.3, “Obtaining Palivizumab” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).
Providers can refer to the following forms:
Form MD.24, “Radiation Therapy” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).
Form MD.14, “Texas Medicaid Vendor Drug Program for Outpatient Pharmacies Synagis (Palivizumab) Prior Authorization Request & Prescription Form for 2011” in the Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook (Vol. 2, Provider Handbooks).

Texas Medicaid & Healthcare Partnership
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