Effective March 1, 2012, most Medicaid clients and all Children’s Health Insurance Program (CHIP) clients are receiving their prescription drug benefits through the managed care service delivery model.
Prescription drug benefits for most Medicaid clients and all CHIP clients are through the client’s managed care organizations (MCOs). Each MCO will contract with a pharmacy benefits manager (PBM) that will process prescription claims and contract and work with pharmacies that serve CHIP and Medicaid managed care clients.
Beginning March 1, the Vendor Drug Program will:
- Still enroll pharmacy providers that want to provide Medicaid and CHIP services.
- Continue to manage Vendor Drug Medicaid and CHIP formularies.
- Continue to process claims for clients enrolled in fee-for-service Medicaid, the DSHS Children with Special Health Care Needs (CSHCN) Services Program, and the DSHS Kidney Health Care (KHC) Program.
- Deny claims for clients enrolled in Medicaid managed care or CHIP with NCPDP error code “AF” (“Patient Enrolled Under Managed Care”). The name of the responsible Medicaid or CHIP health plan will be returned in “Additional Message Information" (Field 526-FQ) to assist pharmacies. Pharmacies should then use the assistance chart to contact the appropriate MCO/PBM.
- Questions about changes should be sent by e-mail to HPM_complaints@hhsc.state.tx.us .