Current News

January 2017 Drug Utilization Review Board Recommendations

February 15, 2017

The Texas Drug Utilization Review Board held their quarterly meeting on January 27, 2017, to make recommendations about clinical prior authorization criteria and drug classes to include on the preferred drug list (PDL).

Clinical Prior Authorizations

Criteria presented:

Criteria approved as presented:

Criteria approved with recommendations:

  • Diabetic Test Strips (PDF)
    • Check for diagnosis of hypoglycemia was added
    • Bypass prior authorization requirement for first 90 days after the first test strip claim
    • Look back period for claim of diabetic medicine extended to last 730 days
    • Look back period for claim of drugs that may induce diabetes extended to last 365 days

Reminder

  • HHSC will notify providers and stakeholders once an implementation date has been set for traditional Medicaid.
  • Medicaid managed care organizations have the option to implement any board-approved clinical prior authorization at any time.

Preferred Drug List

All preferred drug list (PDL) recommendations are pending the final decision of the HHS Executive Commissioner. 

  • January 27, 2017, PDL recommendations (PDF)
  • Approved recommendations from both the January and April 2017 board meetings will be incorporated into the next release of the PDL, scheduled for July 2017. The April 2017 drug class review schedule is also available.

Reminder

  • Prescribing Medicaid providers must adhere to the Medicaid formulary and PDL.
  • Medicaid managed care plans must adhere to the PDL.

Prior Authorizations for Non-Preferred Antipsychotic Drug Vraylar

February 15, 2017

On February 17, HHSC will move the antipsychotic drug Vraylar to a non-preferred status and include the drug as part of the Medicaid antipsychotic clinical prior authorization.  To avoid unexpected interruptions in treatment, a short-term non-preferred and clinical authorization for clients who have had a paid claim for Vraylar capsules within the last 180 days will be created. The short-term prior authorization will have an effective date of February 17, 2017, and a termination date of May 31, 2017.  To continue receiving the medication after May 31, 2017, for clients in traditional Medicaid, prescribing providers will need to request prior authorization either:

The list of Vraylar national drug codes is as follows:
 

National Drug Code (NDC)

Drug Name and Strength

61874011530

Vraylar 1.5 mg capsule

61874013030

Vraylar 3 mg capsule

61874014530

Vraylar 4.5 mg capsule

61874016030

Vraylar 6 mg capsule

61874017008

Vraylar 1.5mg-3mg pack

Medicaid managed care organizations (MCO) are required to implement the same prior authorization requirements.  Please refer to the MCO Resources for links to each MCO's clinical prior authorizations.

February 2017 Texas NDC-to-HCPCS Crosswalk

February 14, 2017

The February 2017 Texas NDC-to-HCPCS Crosswalk is now available for clinician-administered drug processing.

October 2016 Drug Utilization Review Board Meeting Minutes

February 9, 2017

October 2016 Drug Utilization Review Board Meeting Minutes
February 9, 2017

During the most-recent Texas Drug Utilization Review (DUR) Board meeting on January 27, 2017, members reviewed and approved the minutes from their October 14, 2016, meeting.

Pharmacy Payments Delayed Due to the President's Day Holiday

February 6, 2017

There will be a one-day delay in traditional Medicaid (fee for service), Children with Special Health Care Needs Services Program, and Kidney Health Care Program payments to pharmacy providers because of the Presidents' Day holiday on Monday, February 20. Claims submitted between February 10 and February16 will be paid Tuesday, February 21, with deposits available February 23. Claims submitted after February 16 will resume on the regular cycle.

Managed Care Resources Update

January 26, 2017

Updates to the following pharmacy/prescriber assistance charts are now available:

January 2017 Preferred Drug List Published

January 26, 2017

The January 2017 Medicaid Preferred Drug List (PDL) has been published.  The document also includes appendices for cough and cold products, iron oral agents, and prenatal vitamins products.  New additions to the document include a cover sheet with formulary- and PDL-related information, notations for drugs requiring clinical prior authorization, and PDL review schedule.

The "Hypogliycemics, Metformin" class has been added beginning with this PDL update.

The PDL is also available through the Epocrates drug information system.  Please note that Epocrates does not mirror the HHSC designations that are differentiated by dosage form.  In these situations, the designation is accompanied by an explanatory message.

January 2017 Drug Utilization Review Board Testimony Form

January 17, 2017

The Testimony Form for the January 27 Drug Utilization Review Board meeting is available.  Please refer to the public testimony instructions for how and when to use this form.

January 2017 Texas NDC-to-HCPCS Crosswalk

January 13, 2017

The January 2017 Texas NDC-to-HCPCS Crosswalk is now available for clinician-administered drug processing.

Hepatitis C Prior Authorization Revision and Formulary Additions

January 11, 2017

Beginning January 13, HHSC will begin using revised criteria for Hepatitis C prior authorization requests. Providers should review the criteria and forms in their entirety prior to submitting prior authorization requests. The Hepatitis C prior authorization criteria applies to all direct-acting antivirals for Hepatitis C for all Medicaid-eligible individuals (both traditional and managed care).

HHSC will add Epclusa and Viekira XR to the Texas Medicaid formulary effective January 13. Viekira XR is preferred on the preferred drug list (PDL). Epclusa is preferred for genotypes 2 and 3 only. Please refer to the PDL document for a complete listing of preferred and non-preferred direct-acting Hepatitis C agents. Viekira XR and Epclusa will be published as part of the PDL document update on January 26. 

Also on January 13, PAXpress will have the updated forms and policy for traditional Medicaid-eligible individuals.  Prescribers should contact the individual's health plan for forms and submission instructions.  The Prescriber Assistance Chart (PDF) identifies prior authorization call center phone numbers for each plan.

Gastrointestinal Motility Agents Clinical Prior Authorization Begins For Traditional Medicaid

January 11, 2017

HHSC will implement the Agents for Gastrointestinal (GI) Motility Clinical Prior Authorization for traditional Medicaid (fee-for-service) on January 18.  This prior authorization includes Amitiza, Linzess, Lotronex, Movantik, and Relistor.  The clinical prior authorization criteria document is available for review.

Pharmacy Payments Delayed Due to MLK Day Holiday

January 9, 2017

There will be a one-day delay in traditional Medicaid, Kidney Health Care Program, and Children with Special Health Care Needs Services Program payments to pharmacy providers because of the Martin Luther King Jr. Day holiday on Monday, January 16. Claims submitted between January 6 and January 12 will be paid Tuesday, January 17, with deposits available January 19.  Claims submitted after January 13 will resume on the regular cycle. 

Texas Pharmacy Procedure Manual Update

January 6, 2017

An update to the Texas Pharmacy Procedure Manual is available.

January 2017 Preferred Drug List to Implement

December 30, 2016

Effective January 27, 2017, Texas Medicaid will implement the semi-annual update of the Medicaid preferred drug list (PDL).  The update is based on changes presented at the Drug Utilization Review (DUR) Board meetings in July and October 2016.  The "Hypogliycemics, Metformin" class has been added beginning with this PDL update.

Not all drugs on the Texas Medicaid formulary are included on the PDL, and most drugs are identified as preferred or non-preferred.  Drugs identified on the PDL as preferred, or not listed at all, are available to individuals without prior authorization.  Drugs identified as non-preferred require a PDL prior authorization.  In addition, clinical prior authorizations may apply to any individual drug or an entire drug class on the formulary, including some preferred and non-preferred drugs.

The PDL Criteria Guide (PDF) explains the criteria used to evaluate the PDL prior authorization requests.  The criteria guide will be updated by January 18, 2017.

December 2016 Specialty Drug List Published

December 21, 2016

The December 2016 Specialty Drug List is now available.

Antipsychotics Clinical Prior Authorization Criteria Revision

December 20, 2016

HHSC is modifying the antipsychotic clinical prior authorization criteria. Specifically, question #7 of the criteria logic has been revised to remove the requirement of having one claim for an antidepressant agent in the last 60 days as long as they have the proper diagnosis listed in Tables A or B and major depressive disorder.  The revised clinical prior authorization will become effective on January 9, 2017. Since the antipsychotic clinical prior authorization is required for managed care MCOs must make the necessary system updates and revise any associated public documents no later than January 9, 2017.

Pharmacy Education Reminder

December 15, 2016

Pharmacies that are enrolled with Texas Medicaid are in a unique position to help individuals with their pharmacy benefits. It’s important for pharmacy staff to know what pharmacy items Medicaid pays for, which products require prior authorization, and who to contact with questions about claim processing.  More information is available online about the following:

2016 Pharmacy Enrollment Application Revision

December 16, 2016

The Texas Medicaid Pharmacy Provider Enrollment Application (PDF) has been revised.  The previous version of the application dated January 8, 2016, will be accepted through January 13, 2017.  Beginning January 14, 2017, only this new version will be accepted and processed.

December 2016 Texas NDC-to-HCPCS Crosswalk Available

December 14, 2016

The December 2016 Texas NDC-to-HCPCS Crosswalk is now available for clinician-administered drug processing.

Texas Medicaid Extends Mosquito Repellent Benefit for Cameron County

December 9, 2016

HHSC will extend the mosquito repellent benefit for Zika virus prevention indefinitely for Cameron County.  In November, the commission extended the benefit for all other counties through December 31, 2016. 

Suboxone/ Buprenorphine Prior Authorization Criteria

December 8, 2016

On January 5, 2017, the clinical prior authorization criteria for buprenorphine and buprenorphine/naloxone combination products will be modified to change the duration from 30 to 90 days. The duration modification is a result of prescriber feedback.  The revised criteria guide is available.  The Suboxone/Buprenorphine criteria is optional for managed care organizations (MCOs).  The Pharmacy Clinical Prior Authorization Assistance Chart (PDF) identifies which criteria are utilized by each MCO and how those criteria relate to those used for traditional Medicaid claim processing.  The drugs impacted by this change are noted below:

NDC

              Label

00054017613

 BUPRENORPHINE 2 MG TABLET SL

00093537856

 BUPRENORPHINE 2 MG TABLET SL

00228315603

 BUPRENORPHINE 2 MG TABLET SL

00378092393

 BUPRENORPHINE 2 MG TABLET SL

50383092493

 BUPRENORPHINE 2 MG TABLET SL

00054017713

 BUPRENORPHINE 8 MG TABLET SL

00093537956

 BUPRENORPHINE 8 MG TABLET SL

00228315303

 BUPRENORPHINE 8 MG TABLET SL

00378092493

 BUPRENORPHINE 8 MG TABLET SL

50383093093

 BUPRENORPHINE 8 MG TABLET SL

59385001230

 BUNAVAIL 2.1-0.3 MG FILM

59385001430

 BUNAVAIL 4.2-0.7 MG FILM

59385001630

 BUNAVAIL 6.3-1 MG FILM

12496120203

 SUBOXONE 2 MG-0.5 MG SL FILM

12496120403

 SUBOXONE 4 MG-1 MG SL FILM

12496120803

 SUBOXONE 8 MG-2 MG SL FILM

12496121203

 SUBOXONE 12 MG-3 MG SL FILM

00054018813

 BUPRENORPHN-NALOXN 2-0.5 MG SL

00093572056

 BUPRENORPHN-NALOXN 2-0.5 MG SL

00228315473

 BUPRENORPHN-NALOXN 2-0.5 MG SL

65162041603

 BUPRENORPHN-NALOXN 2-0.5 MG SL

00054018913

 BUPRENORPHIN-NALOXON 8-2 MG SL

00093572156

 BUPRENORPHIN-NALOXON 8-2 MG SL

00228315573

 BUPRENORPHIN-NALOXON 8-2 MG SL

65162041503

 BUPRENORPHIN-NALOXON 8-2 MG SL

54123091430

 ZUBSOLV 1.4-0.36 MG TABLET SL

54123095730

 ZUBSOLV 5.7-1.4 MG TABLET SL

Texas Medicaid Brings Back Mosquito Repellent Benefit

November 28, 2016

The Texas Health and Human Services Commission has reactivated the mosquito repellent benefit for Zika virus prevention for all programs previously covered by the benefit, including Medicaid (both fee for service managed care), CHIP, the Healthy Texas Women (HTW) Program, and Children with Special Health Care Needs Program.  This also includes the Texas Standing Order for Medicaid- and CHIP-eligible individuals.  The benefit begins immediately and continues through December 31, 2016.

Atropine 1% Eye Drops Shortage

October 7, 2016

Atropine 1% eye drops have been reported by some pharmacies and prescribers as being in short supply. In response, VDP has added the following 3 products to the formulary, effective October 3, 2016.  These drugs are available now for fee-for-service Medicaid and Medicaid managed care clients and Children with Special Health Care Needs (CSHCN) Services Program clients.

National Drug Code (NDC) Drug name Unit of measure Package size
17478-0215-02  Atropine 1% eye drops  Milliliter  2
17478-0215-05  Atropine 1% eye drops  Milliliter  5
17478-0215-15  Atropine 1% eye drops  Milliliter  15

A complete list of formulary products containing atropine may be found at the VDP Formulary Lookup.

September 2016 Preferred Drug List Published

September 19, 2016

The September 2016 Specialty Drug List, effective September 15, is now available.

Children with Special Health Care Needs (CSHCN) Services Program Covers Mosquito Repellent with a Prescription

September 1, 2016

CSHCN now covers mosquito repellents to protect against the Zika virus. A prescription from a CSHCN client's health care provider is required. Eligible clients include females ages 10 to 45 and pregnant women of any age. Please refer to the pharmacy notice (PDF) for benefit details and claims submission information.  

July 2016 Preferred Drug List Revised

August 18, 2016

The July 2016 Medicaid Preferred Drug List (PDL) has been revised, effective August 12, 2016.  The document also includes appendices for cough and cold products, iron oral agents, and prenatal vitamins products.  The PDL is also available through the Epocrates drug information system.  Please note that Epocrates does not mirror the HHSC designations that are differentiated by dosage form.  In these situations, the designation is accompanied by an explanatory message.

Texas to Issue Standing Order for Mosquito Repellent to Fight Zika

August 15, 2016

Texas Medicaid has issued a Texas Medicaid Standing Order for Mosquito Repellent. This is a standing order that may be used for individuals enrolled in Medicaid (either fee for service or managed care) or the Children Health Insurance Program (CHIP). This Standing Order serves as a prescription and allows pharmacists to dispense mosquito repellent under the terms of the Standing Order. Pharmacies are encouraged to use this Standing Order instead of contacting individuals' healthcare providers for individual prescriptions for mosquito repellent.

Pharmacists should reference the Texas Medicaid Standing Order for Mosquito Repellent for details related to operating under the Standing Order.  See below for additional information and tools to assist with claims processing, including a prescription template for pharmacies.

Pharmacies may obtain a copy of the Texas Medicaid Standing Order for Mosquito Repellent upon request by email to vdp_formulary@hhsc.state.tx.us. Please include the pharmacy National Provider Identifier in the request.  A prescription from a valid healthcare provider is required for any pharmacy/pharmacist not operating under a standing order, for the dispensing of mosquito repellent to eligible Medicaid or CHIP individuals.

Healthy Texas Women (HTW) program
The Texas Medicaid Standing Order for Mosquito Repellent may not be used for individuals in the HTW program.  A prescription is not required for individuals enrolled in the HTW program. The below information should be used to process claims for individuals in the Healthy Texas Women program.

  • Provider name field: Zika, Zika (Last Name, First Name)
  • Address: 4900 N. Lamar Blvd, Austin, TX 78751
  • NPI: 1234568883
  • License: 2126X

Medicaid Will Pay for Mosquito Repellent to Fight Zika

August 4, 2016

The Centers for Medicare & Medicaid Services (CMS) released an informational bulletin on Medicaid benefits available for the prevention, detection, and response to the Zika virus. The CMS bulletin allows state Medicaid programs to choose to cover mosquito repellents when prescribed by an authorized healthcare professional and provided as a pharmacy benefit.
Starting August 9, 2016, Texas will cover select mosquito repellents under the Medicaid Fee For Service (FFS) and managed care organizations (MCO), CHIP and HTW programs.  The mosquito repellent benefit is available through October 31, 2016.
Note: at this time the KHC Program and CSHCN Services Program will not cover these products

Mosquito Repellent Benefit Description

  • Covered population: Any female aged 10 - 45 years; pregnant women of any age
  • Quantity: One (1) can/bottle per fill, with 1 optional refill available per calendar month.
  • Mosquito repellent will not count against clients' monthly three (3) prescription limit. (FFS only).
  • CHIP clients may be subject to any applicable generic copays.

More information is available, including the list of covered products.

July 2016 Preferred Drug List Published

July 18, 2016

The July 2016 Medicaid Preferred Drug List (PDL) has been published.  The document also includes appendices for cough and cold products, iron oral agents, and prenatal vitamins products.

The PDL is also available through the Epocrates drug information system.  Please note that Epocrates does not mirror the HHSC designations that are differentiated by dosage form.  In these situations, the designation is accompanied by an explanatory message.

Consolidation of Fee-For-Service Pharmacy Payment Files

July 11, 2016

Beginning September 1, 2016, the Vendor Drug Program will no longer issue separate payments for Medicaid, the Kidney Health Care Program, or Children with Special Health Care Needs Services Program.  Instead, pharmacy providers will receive a consolidated payment and remittance advice.  The first pharmacy payment affected by this consolidation will be for payment date September 5, 2016. 

July 2016 Preferred Drug List to Implement

July 8, 2016

Effective July 21, 2016, Texas Medicaid will implement the semi-annual update of the Medicaid Preferred Drug List (PDL). The update is based on changes presented at the January 2016 Pharmaceutical and Therapeutics Committee meeting and April 2016 Drug Utilization Review Board meeting.

Drugs listed on the PDL as "preferred" are not subject to PDL prior authorization.  Not all drugs on the Texas Medicaid formulary are listed on the PDL documents and therefore are not subject to PDL prior authorizations.

For this update of the PDL no new classes were reviewed.

The PDL Criteria Guide (PDF) explains the criteria used to evaluate the PDL prior authorization requests.  The criteria guide will be updated by July 15, 2016.

Ingredient cost, Dispensing fee changes coming June 1

May 20, 2016

Pursuant to the Covered Outpatient Final Rule of the Affordable Care Act of 2010, states that have outpatient drugs as a benefit of their Medicaid programs must move from an estimated acquisition cost (EAC) -based system to an actual acquisition cost (AAC) model. AAC is the agency’s determination of a pharmacy provider’s actual prices paid to acquire drug products marketed or sold by specific manufacturers. The change to AAC represents a more accurate reference price to be used by states to reimburse pharmacies.

To meet the requirements of the final rule, VDP will change the fee for service (FFS) pharmacy reimbursement methodology effective June 1, 2016. This change only affects the claims processed by VDP and is not related to and does not impact managed care organization reimbursement rates.

Ingredient cost
Ingredient costs will differ by the type of pharmacy. The new methodology will utilize the National Average Drug Acquisition Cost (NADAC), the new benchmark of retail pharmacy acquisition costs developed by the Centers for Medicare & Medicaid Services (CMS). VDP will use a drug’s wholesale acquisition cost (WAC) price when no NADAC pricing is available.

  • Retail pharmacy ingredient cost will equal the NADAC price, or (WAC minus 2 percent), if no NADAC price
  • Long-term Pharmacy (LTC) pharmacy ingredient cost equals (NADAC minus 2.4 percent), or (WAC minus 3.4 percent), if no NADAC price
  • Specialty pharmacy ingredient cost equals (NADAC minus 1.7 percent), or (WAC minus 8 percent), if no NADAC price

Dispensing fee
The professional dispensing fee includes a variable component. It now reflects a pharmacist’s professional services and costs incurred when dispensing a drug to a Medicaid client. The fee will be equal to $7.93 plus 1.96 percent of the ingredient cost, per claim.

90% Utilization Drug List Available

May 6, 2016

An update to the VDP 90% Utilization Drug List (PDF) is available. Clients must use at least 90 percent of the prescribed supply before obtaining a refill of certain controlled substances, as well as Tramadol. This applies to clients enrolled in Fee-For-Service Medicaid, the DSHS Kidney Health Care (KHC) Program, and the DSHS Children with Special Health Care Needs (CSHCN) Services Program.

This list of drugs is available through the Drug Formulary Lookup. Click the “90% Utilization” indicator on the lookup and the returned results will include only those drugs where a 90% refill is required. The weekly formulary data can also be downloaded at any time.

DUR Board By-laws Available

May 6, 2016

The Texas Drug Utilization Review (DUR) Board met Friday, April 29, 2016, and approved its by-laws.

May 2016 NDC-to-HCPCS Crosswalk Removes Additional 'Unclassified Drugs'

March 18, 2016

The May 16, 2016, release of the Texas NDC-to-HCPCS Crosswalk will include additional procedure code termination dates of the National Drug Codes (NDC) associated with procedure code J3490 ("unclassified drugs") and other ("not otherwise classified") procedure codes. These NDCs have been identified as "incident to” services and are not appropriately billed using this code. The list of NDCs removed in May is available on our clinician-administered drug resources page.

The NDCs terminated as medical benefits may still be available as pharmacy benefits if the NDC is on the Medicaid formulary.