Providers must obtain palivizumab vaccine for FFS patients through VDP

posted 10.03.13

Providers prescribing palivizumab to fee-for-service Medicaid patients must now get the vaccine through the Texas Vendor Drug Program. The Texas Medicaid and Healthcare Partnership will no longer give prior authorizations for the drug or reimburse claims for procedure code 90378 taking place on or after Oct. 1.

This change will eliminate the buy-and-bill option previously offered through TMHP. According to the Texas Health and Human Services Commission, out of the thousands of babies who received palivizumab last year through the Medicaid program, less than 300 received it via buy-and-bill, always outside of their medical homes. HHSC is hoping this will promote medical homes as it will allow primary care physicians to continually treat these higher-risk babies.

Prescribing providers or pharmacy providers must submit the request for prior authorization by completing the Texas Medicaid Vendor Drug Program Palivizumab (Synagis) Prior Authorization Request Form and faxing it to the Texas Prior Authorization Call Center at (866) 617-8864. Physicians with questions regarding a request can call (877) 728-3927.

More instructions on prescribing palivizumab through VDP, including the request form itself and a list of participating pharmacies, can be found at www.txvendordrug.com/dur/synagis.shtml.