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December 2016 Texas Medicaid Provider Procedures Manual

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/pa/rsv.
Palivizumab forms are updated every year. Providers must use the most current version of the forms to submit prior authorization requests.
The Texas Medicaid/CHIP Vendor Drug Program Fee-For-Service Medicaid Synagis® Request Form for 2016-17 Season is required when the prescribing provider obtains the drug through VDP.
Note:
Refer to:

Texas Medicaid & Healthcare Partnership
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