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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

For a list of participating pharmacies, refer to the HHSC Vendor Drug website at
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.
Refer to:

Texas Medicaid & Healthcare Partnership
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