Formulary Information
Overview
The Texas Drug Code Formulary covers more than 32,000 line items of drugs including single source and multi source (generic) products. The Vendor Drug Program only reimburses pharmacy providers for outpatient prescription drugs.
Drug Coverage
DME
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. Learn more about enrolling as a DME and supply provider.
Certain Vitamins and Minerals Are CCP Benefit
Certain vitamin and mineral products prescribed or ordered by a physician to treat various conditions will be a benefit of Texas Medicaid through the Texas Medicaid Children’s Comprehensive Care Program (CCP) for clients who are 20 years of age and younger. The certain vitamin and mineral products will be billed to TMHP, manually priced, and will be a benefit when they are prior authorized and submitted with the corresponding procedure code and state-identified modifier: For list of vitamin and minerals, procedure codes, and state identified modifiers, see the Benefit Criteria for Vitamin and Mineral Products to Change for Texas Medicaid article in September/October 2011 edition of the TMHP Texas Medicaid Bulletin.
Insulin and syringes
Vendor Drug pays for insulin and insulin syringes, but only when the syringes are for insulin use. If insulin syringes are prescribed for other injectable drugs then they should be billed through the Texas Medicaid & Healthcare Partnership (TMHP). Only the Insulin (not the syringes) counts toward a limited client’s three prescriptions limit. For insulin claims, it is acceptable to submit a day supply based on stability rather than the actual dose.
Identifying the Correct Units
Products such as Risperdal Consta, Humira, Enbrel, Lovenox, Neupogen, Pegasys, and Procrit have varying units depending on the 11-digit National Drug Code (NDC). Pharmacies should be aware of the correct billing units for these medications to alleviate billing discrepancies and eventual audits.
Metric Decimal Quantity Package Sizes
Many National Drug Code (NDC) numbers are packaged in a size that is not a whole number. When entering a claim for a drug that is packaged in a metric decimal sized package, please ensure to include the decimals on your claims and do not round up. Incorrect quantities may prompt drug manufacturers to dispute the claim and the drug rebate auditors provided by Vendor Drug's rebate administrator to review the claim level data. To learn more please refer to the Pharmacy Provider Procedure Manual, specifically section 4.3 Dispensing Limits.
