Pharmacy Participation

Medicaid Fee-For-Service (FFS), Kidney Health Care (KHC), and Children with Special Health Care Needs (CSHCN)

To provide limited home health supplies (LHHS) to clients in FFS, KHC, and the CSHCN pharmacies must be contracted with the Vendor Drug Program (VDP). Enrollment as a durable medical equipment (DME) provider is not required. Pharmacies already enrolled as a Medicaid DME provider have the choice to submit a claim for LHHS to either the Texas Medicaid Healthcare Partnership (TMHP) or the VDP.  

Medicaid Managed Care

To provide LHHS to clients enrolled in a Medicaid managed care organization (MCO), pharmacies must be contracted with the VDP and with the MCO’s pharmacy benefit manager (PBM). Pharmacies are required to work with the MCO or PBM in their service area to determine the billing requirements, reimbursements rates, and coverage limitations for these products. Medicaid MCOs have the ability to designate certain LHHS products as preferred. Please contact the appropriate MCO or PBM for specific requirements related to LHHS products.

Covered Products, Reimbursement Rates, and Quantity Guidelines for Medicaid FFS, KHC, and CSHCN

These LHHS are classified as a Title XIX (Medicaid) home health benefit as Durable Medical Equipment or Medical Supplies. Reimbursement rates are based on the Texas Medicaid Fee Schedule. Pharmacies will not be paid a dispensing fee or delivery fee for providing these LHHS. Quantity guidelines are based on the Medicaid DME and Medical Supplies policies. The following tables provide pertinent information for each covered product:

Table 1: Descriptions, Codes, Reimbursement, and Quantity Limits
Description and HCPCS* VDP
Billing
Unit
VDP Unit Price VDP Max Billable Units per Filling
Insulin Syringes (1 cc or less) – A4206 EA $  0.23000 100
Insulin Needles – A4215 EA $  0.18000 100
Blood Glucose Test Strips (for home blood glucose monitor) – A4253 EA $  0.56560 100
Blood Glucose Test Strips with Disposable Monitor – A9275 EA $  0.56560 100
Blood Glucose Monitor (Talking) – E2100 EA $  312.80000 1
Lancets – A4259 EA $  0.11100 100
Spring-Powered Device for Lancet – A4258 EA $  14.65000 1
Aerosol Holding Chamber (for use with metered dose inhaler) – A4627 EA $  27.60000 1
Oral Electrolyte Replacement Fluid – B4103 ML $  4.51000 per 500 ML
or
$  0.00902 per ML
2000
Hypertonic Saline Solution 7% - T1999 ML (AWP-10.5%) - 8% 1800
Hypertonic Saline Solution 3% - T1999 ML (AWP-10.5%) - 8% 1800
Table 2: Descriptions, Codes, and Quantity Guidelines
Description and HCPCS* Quantity Guidelines
Insulin Syringes (1 cc or less) – A4206

  • A refill may not be dispensed until 75% of the day supply has been used.
Insulin Needles – A4215

  • A refill may not be dispensed until 75% of the day supply has been used.
Blood Glucose Test Strips (for home blood glucose monitor) – A4253

  • Maximum: 100 units per calendar month.
  • Limited to a 30-day supply.
  • A refill may not be dispensed until 100% of the day supply has been used.
Blood Glucose Test Strips with Disposable Monitor – A9275

  • Maximum: 100 units every calendar month.
  • Limited to a 30-day supply.
  • A refill may not be dispensed until 100% of the day supply has been used.
Blood Glucose Monitor (Talking) – E2100

  • Maximum: 1 unit per three rolling years.
  • Only available for clients with visual impairment.
Lancets – A4259

  • Maximum: 100 units every calendar month.
  • Limited to a 30-day supply.
  • A refill may not be dispensed until 100% of the day supply has been used.
Spring-Powered Device for Lancet – A4258

  • Maximum: 2 units per rolling year.
Aerosol Holding Chamber (for use with metered dose inhaler) – A4627

  • Maximum: 1 unit every 180 days.
Oral Electrolyte Replacement Fluid – B4103

  • A refill may not be dispensed until 75% of the day supply has been used.
Hypertonic Saline Solution 7% - T1999

  • A refill may not be dispensed until 75% of the day supply has been used.
Hypertonic Saline Solution 3% - T1999 A refill may not be dispensed until 75% of the day supply has been used.

*Healthcare Common Procedure Coding System (HCPCS) Codes are CMS codes.

Claim Submission for Medicaid FFS, KHC, and CSHCN

Please keep the following in mind when submitting a LHHS claim:

  • Claims must be submitted in accordance with the most current NCPDP pharmacy billing standard
  • Prescriptions for diabetic test trips, lancets, and diabetic disposable monitor and test strips kit are all limited to a max of 5 refills.
  • Claims must include the specific NDC for each product.
  • The only products available to clients in the Kidney Health Care Program are: diabetic insulin syringe with needle 1cc or less, diabetic insulin needles, diabetic blood glucose test strips, and diabetic lancets. 
  • If the prescribed quantity exceeds the quantity guidelines, the claim will reject.
  • If it is medically necessary for the prescribed quantity to exceed the maximum unit per filling a pharmacy will be required to submit additional information for the claims for blood glucose test strips, blood glucose test strips with disposable monitor, diabetic lancets, aerosol holding chamber, spring powered device for lancet, and blood glucose monitor (talking) to be accepted.
    • The pharmacy must attest that the submitted quantity is the actual quantity prescribed in accordance with the directions for use specified on the prescription by resubmitting the claim with “2” in “Submission Clarification Code” (Field 42Ø-DK).

Additional Important Information

  • There is no prescription limit for children under 21 in Medicaid FFS and CSHCN.
  • LHHS claims do not count towards the clients three prescription limit in FFS.
  • LHHS claims for Kidney Health Care will count towards the clients four prescription limit per month.
  • A refill of a prescription for insulin syringes, insulin needles, oral electrolyte, and hypertonic saline solution may not be dispensed until 75% of the day supply has been used. 
  • A refill of a prescription for blood glucose test strips or lancets may not be dispensed until 100% of the day supply has been used.  For example, if a 30-day supply of lancets is dispensed, the client is not eligible for another 30-day supply until the 31st day after the last refill of lancets was dispensed.  Medicaid DME providers should continue to bill for LHHS through TMHP (for their patients in FFS); in accordance with the Texas Medicaid Provider Procedures Manual (TMPPM) DME and Supplies Handbook
  • Claims will be subject to post payment desk reviews to ensure claims from DME providers and pharmacies do not result in a client exceeding the maximum quantity or HHSC making a duplicate payment for the same client / LHHS.
  • A Title XIX form is not required for LHHS dispensed through a pharmacy. A prescription (faxed, written, or electronic) is required with the following information:
    • Client’s name
    • Description of the LHHS to be provided.
    • Quantity to dispense (quantity per day or month)
  • For pharmacies that require a client signature when a filled prescription is picked up, a client signature should also be required when picking up LHHS.  (The DME Certification and Receipt Form is not required.)

Pharmacies can call the VDP Resolution Helpdesk at
1-800-435-4165 for assistance with Medicaid FFS, KHC, or CSHCN