Pharmacy Benefit

Certain supplies that are covered benefits of Texas Medicaid can be provided by a pharmacy enrolled in the Vendor Drug Program (VDP).  This limited set of home health supplies (HHS) are classified as a Title XIX (Medicaid) home health benefit and as durable medical equipment or medical supplies.  These products are available to individuals enrolled in Medicaid, the Children’s Health Insurance Program (CHIP), the Children with Special Health Care Needs (CSHCN) Services program, and the Kidney Health Care (KHC) program.

Pharmacies are not required to enroll as a durable medical equipment (DME) provider to provide access to supplies.  Pharmacies that have already enrolled as a Medicaid DME provider have the choice to submit claims for HHS products to the Texas Medicaid Healthcare Partnership (TMHP) as a medical benefit or pharmacy benefit.   Please refer to the Home Health Supplies (PDF) chapter of the VDP Pharmacy Provider Procedure Manual (PPPM) to learn more.

  • Claims for fee-for-service Medicaid, CSHCN Services Program, and KHC program are submitted to VDP.  Pharmacy staff should refer to the Pharmacy Benefit Chart in the PPPM for covered products (including those only available to KHC-eligible individuals), quantity guidelines, refill limitations, and reimbursement rates. 
  • Claims for Medicaid and CHIP managed care members are submitted to the managed care organization (MCO).  Pharmacy staff must work with the MCO's pharmacy benefit manager to determine the billing requirements, reimbursement rates, and coverage limitations for these products.