As a pharmacy contracted with the Vendor Drug Program, it is important for your staff to know what pharmacy items Medicaid covers, and to know where to access information on the clinical edits and the preferred drug list (PDL). You are in a unique position to assist Medicaid clients and provide access to the whole array of pharmacy benefits.
The Vendor Drug Pharmacy Resolution Desk is available to assist pharmacies Monday through Friday, 8:30 a.m. - 5:30 p.m. If you would like to request assistance with in-house training for your pharmacy regarding any of this information, please contact us at 1-800-435-4165.
The Vendor Drug Program's pharmacy outreach initiatives are included in the Rx Update, our quarterly newsletter. |
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Reminders:
Pharmacy Initiatives:
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Comprehensive Care Program Assists Medicaid Children
The Texas Medicaid Comprehensive Care Program (CCP) can cover medically necessary drugs and supplies that are not available through the Medicaid Vendor Drug Program for clients birth through 20 years of age. Pharmacies should inform the family (or physician) that they can request coverage through CCP. Pharmacies not enrolled as CCP providers, may direct the client to call the Texas Medicaid & Healthcare Partnership (TMHP) at 1-800-335-8957 to locate a CCP provider.
Pharmacies enrolled with VDP are eligible to enroll with TMHP as CCP providers. This enrollment allows pharmacies to bill TMHP for medically necessary drugs, equipment, or supplies (e.g. some over-the-counter drugs, nutritional products, and disposable or expendable medical supplies commonly found in pharmacies) not covered by Medicaid VDP. To enroll online, complete an application from the TMHP “Provider Enrollment” website. Pharmacy providers can also download and print the application from the website. Once completed, it can be mailed to the address provided on the website. For further assistance, contact the TMHP Contact Center at 1-800-925-9126, or visit the TMHP “Regional Support” website to find contact information for the local TMHP provider relations representative in your area.
Prior authorization is required for all services available through CCP. Prior authorization requirements, including forms and documentation required from the prescribing physician (e.g., prescription or letter of medical necessity), can be found in the Texas Medicaid Provider Procedures Manual located at www.tmhp.com or by calling the TMHP Prior Authorization Unit at 1-800-846-7470. If a client is in a Medicaid Health Plan (Health Maintenance Organization [HMO]) or Primary Care Case Management, contact the client’s Medicaid HMO directly for the letter of medical necessity, prior authorization, or for further assistance.
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| Temporary Medicaid Eligibility Verification Form (1027-A)
Medicaid clients may present the Temporary Medicaid Eligibility Verification form (Form 1027-A) as evidence of Medicaid eligibility. While Form 1027-A might not have a Medicaid number, it is an official state eligibility document and can be relied upon as proof of Medicaid eligibility until the family receives the Medicaid Identification Form (Form H3087). Medicaid numbers should be assigned within one month of the original presentation of Form 1027-A.
Vendor Drug strongly encourages pharmacies to fill the prescription immediately and then bill as soon as the Medicaid number is assigned. They can also submit the paper Pharmacy Claims Billing request (Form 3700) and the claim will be paid when the Medicaid number is posted.
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Separate billing for Outpatient Prescriptions and DME
The Vendor Drug Program reimburses providers for outpatient prescription drugs only. Drugs administered in the doctor's office, inpatient hospital, outpatient hospital, or any location other than the client's home, nursing facility, or extended care facility are not a covered Vendor Drug Program benefit. Physician-administered drugs must be provided by the medical provider at the time of administration.
Pharmacies are encouraged to provide durable medical equipment (DME) and medical supplies to Medicaid clients. Reimbursement for DME is different from drug claims; pharmacy providers must enter into a separate written agreement with HHSC, through the Texas Medicaid & Healthcare Partnership (TMHP). To enroll online, complete an application from the TMHP “Provider Enrollment” website. For further assistance about completing the application contact the TMHP Contact Center at 1-800-925-9126, or visit the TMHP “Regional Support” website to find contact information for the local TMHP provider relations representative in your area. Some clients are enrolled in Medicaid managed care health plans; for those clients pharmacies must enter into a contract with their individual health plans to be reimbursed for DME and medical supplies.
TMHP presents a number of free DME workshops throughout the year where prospective DME providers will learn about the DME provider application and other information needed to get started. Pharmacies interested in providing DME services to clients enrolled in Medicaid are encouraged to attend. To learn more and view a schedule of seminars, please visit the TMHP “Workshops” website. |
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Online Continuing Medicaid Education Courses
The Texas Health and Human Services Commission has a series of free, computer-based training opportunities for pharmacies to educate staff about Medicaid pharmacy benefits (particularly for children under 21) and how to get reimbursed. The course is accredited by Accreditation Counsel of Pharmacy Education (ACPE). Providers can access the training at www.txhealthsteps.com.
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Submitting an Eligibility Verification Transaction (E1)
Vendor Drug encourages pharmacy providers to use the National Council for Prescription Drug Programs Eligibility Verification Transaction (E1) to check eligibility data for individuals enrolled in Medicaid, Children’s Health Insurance Program, Children with Special Health Care Needs (CSHCN) Services Program, or the Kidney Health Care program.
If you do not know an individual’s Cardholder ID, you can submit the individual’s Social Security number, preceded by an ‘S’ (e.g., S123456798), to receive the client’s Cardholder ID on the returned response. When you submit the Cardholder ID you will receive the following information:
- The client’s most current or last effective Medicaid eligibility period (pertaining to the date submitted).
- The client’s prescription limitations, if any.
- Whether or not the client had periods of prior eligibility.
- Whether or not the client is enrolled in a secondary program, such as CSHCN.
- Whether the client has Medicare coverage.
Payer sheets for the E1 transaction are available in the Vendor Drug Procedure Manual. Providers should contact their software vendors to discuss specific E1 submission questions.
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High-volume Pharmacies to Educate Employees about Medicaid Fraud
As directed by Section 6032 of the Federal Deficit Reduction Act (DRA) of 2005, effective January 1, 2007 all providers and other entities that receive or make annual Medicaid payments of $5 million or more must educate their employees, contractors, and agents about federal and state fraud and false claims laws, and the whistleblower protections available under those laws.
Further details are available at www.hhsc.state.tx.us/medicaid/Provide_Notification.pdf. |
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