Referral Form

New! Texas Medicaid Vendor Drug Program

AAIC Pharmacy has been designated as a Preferred Provider and is an approved member of the MedImmune Synagis Distribution Network. We are able to provide Synagis under this program to your Traditional Texas Medicaid and PCCM clients. To participate, you will need to contact AAIC and make arrangements. You will need the Synagis Prescription Form below. It is directly from the Texas Medicaid.  The second form is for a request for reconsideration. You will only need that if we cannot qualify your patient.

Download Instructions: right click and choose "Save Target As" or "Save" or print directly from the PDF file that opens after left click.

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