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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.54 Palivizumab Injections : 8.2.54.3 Obtaining Palivizumab

8.2.54.3
Providers have two options for obtaining palivizumab for Medicaid clients: purchase and bill for palivizumab; or to obtain the drug through the VDP.
Option 1–Texas Medicaid reimbursement for palivizumab:
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The injection provider bills for the drug, an injection administration fee, and any medically necessary office-based E/M service provided at the time of injection.
5)
Option 2–Obtaining palivizumab through the VDP
1)
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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. Not all pharmacies participate in VDP for the palivizumab distribution program.
Refer to:
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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 is mailed to the client’s family, informing them of RSV and palivizumab’s benefits and side effects.
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10)
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 Texas Medicaid for the drug.
11)
The following client demographic information is required:

Texas Medicaid & Healthcare Partnership
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