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.
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.
Billing Reminders
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 (i.e. 10.2, 2.5, 6.8 etc.), be sure to include the decimals on your claims and do not round up. For example, Symbicort (00186-0370-20) is a 10.2 gm inhaler. When you dispense one inhaler, you should be entering 10.2 in the "Quantity Dispensed" field (442-F7). The same goes for drugs like the Atrovent HFA Inhaler (NDC 00597-0087-17) where the package quantity is 12.9 gm for 1 inhaler. When dispensing ophthalmic drops be sure to include the decimal quantity and do not round up.
Many of these issues are resolved by having the pharmacy update their drug file with the rounded/whole number units on the "Package Size" and the true decimal units on the "Metric Decimal Size" fields. The majority of these products that are affected by this error are ear drops, eye drops and eye ointments, inhalers, and injectables. Please verify the units that are being submitted to Vendor Drug are accurate for the claim and product being submitted. If the pharmacy cannot correct the drug file and is continuing to have issues with billing invalid units, then the pharmacy must follow up with their software vendor for further assistance with the issue.
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.
Maximum Allowable Cost (MAC) Updates
Related Information
