News Archive

Drug Utilization Review (DUR) Committee: November Meeting Date and Location Change

October 2, 2012

The November DUR committee meeting originally scheduled for November 15, 2012,  has been rescheduled to November 8, 2012 at 10:00a.m. at the location below:

West Pickle Research Building
3925 W. Braker Ln.
Austin, TX  78759

Pharmaceutical and Therapeutic (P&T) committee: November Meeting Date and Location Change

October 2, 2012

The November P&T committee meeting originally scheduled for November 16, 2012, has been rescheduled to November 9, 2012 at 9:00a.m. at the location below:

West Pickle Research Building
3925 W. Braker Ln.
Austin, TX  78759

HHSC Specialty Drug List

September 13, 2012

The Vendor Drug Program has posted the quarterly update of the Specialty Drug List.

Pharmaceutical & Therapeutics Committee Recommendations Posted

September 13, 2012

The Pharma-
ceutical and Therapeutic Committee's recommendations made at the August 2012 meeting regarding which drugs to place on the Medicaid Preferred Drug List have been posted.

2012-2013 RSV Season

August 17, 2012

Prior approvals for Synagis will be available through the Vendor Drug Program beginning September 15, 2012.  The start of the 2012-2013 respiratory syncytial virus (RSV) season varies based on a patient’s county of residence, with most areas in Texas beginning October 1, 2012. To learn more about the Vendor Drug Synagis process and get the county schedule, visit txvendordrug.com.

Vendor Drug Program Clinical Edits - New and Updated

July 18, 2012

On Wednesday, July 18, the Vendor Drug Program (VDP) implemented the following clinical edit changes. Detailed information regarding the clinical edits and algorithms can be found on the VDP website. 


New Clinical Edits

  • Imiquimod
  • Lovaza 
  • Vicotoza
  • Valturna
  • Aliskiren-containing Agents (except Valturna)
  • Dextromethorphan Overutilization

Updates to Existing Clinical Edits

  • Sitagliptin 25 mg will be removed from Drug Regiment Optimization edit.
  • Sitagliptin 50 mg will be removed from Drug Regiment Optimization edit.


Delayed Addition of Limited Home Health Supplies to Medicaid Formulary

June 14, 2012

The Texas Health and Human Services Commission (HHSC) has delayed the addition of limited home health supplies (LHHS) to the Medicaid Vendor Drug Program (VDP) formulary.

Fee-for-service (FFS) pharmacies should continue to submit claims for home health supplies to the system they currently bill for payment. If the beneficiary is enrolled in Medicaid managed care, these products should continue to be accessed through the client’s managed care health plan.

HHSC will notify FFS and managed care pharmacies and durable medical equipment providers before the addition of LHHS to the Medicaid VDP formulary.  The VDP plans to begin reimbursing pharmacies for dispensing the following classes of items:

  1. Diabetic insulin syringe with needle 1cc or less
  2. Diabetic insulin needles
  3. Diabetic blood glucose test strips
  4. Diabetic lancets
  5. Diabetic blood glucose monitor with integrated voice synthesizer
  6. Disposable diabetic home glucose monitor packaged with test strips
  7. Aerosol holding chamber
  8. Oral electrolyte solutions
  9. Orally administered iron salts
  10. Hypertonic saline solution

These items will be added to the formulary as contemplated in Texas Administrative Code (TAC) 1 TAC §354.1042.  Under this rule, HHSC will post the list of LHHS added to the formulary on its website once the list is available.  

For more information about the current process for providing these supplies, please refer to the DME page on the Vendor Drug website.  Pharmacies may also contact the VDP Pharmacy Resolution Help Desk at 1-800-435-4165 for FFS clients or the client’s health plan for managed care clients.  

Starting July 1 Claims Submitted with Group ID “TXVDP” Will Reject

June 14, 2012

On July 1, 2012, pharmacies will be required to submit the appropriate program-specific Group ID on all B1, B2, and E1 transactions.  For a fee-for-service (FFS) claim, the accepted values in the “Group ID” field (Field 3Ø1-C1) are “MEDICAID”, “CHIP”, “KHC”, or “CSHCN”.  If an improper Group Id is submitted for a FFS claim, the claim will reject with error code “Ø6” (M/I Group Number). 

Please contact your software provider regarding the preparedness of your system.  

Funds Collected from Medicaid Recipients

June 14, 2012

This is a reminder to pharmacy providers that they may not collect co-pays or any other fees from Medicaid clients.  The only exception is if the client, in addition to Medicaid, has Medicare Part D coverage and the prescription is for a Medicare Part D plan covered medication.  The co-pay is assessed by the Medicare Part D plan portion of the claim. 

For more information, please refer to the Vendor Drug Pharmacy Provider Handbook-4800 Limitations on Provider Charges to Recipients.

Medicaid Coverage of Co-Insurance for Medicare Part B Immunosuppressant Drugs

April 2, 2012

On January 1, 2012, HHSC implemented changes to the reimbursement methodology for claims submitted to Medicaid as the secondary payer after Medicare has paid its share – also called “crossover claims.”  This change caused some crossover claims for immunosuppressant and other Part B drugs to pay at zero.  HHSC acknowledges that these claims may be eligible for reimbursement and we are working on a technical solution to allow you to resubmit them.  In the meantime, however, please continue to provide immunosuppressant drugs to your Medicaid/Medicare patients and HHSC will work with you to provide appropriate reimbursement for those prescriptions and prescriptions that you have already filled. 

Medicaid clients who are also covered by Medicare Part B (dual eligibles) may have all or a portion of their co-insurance and deductible amounts paid by Medicaid.  For a crossover claim for an immunosuppressant or other specified Part B drugs dispensed to a dual eligible client after the changes implemented January 1, 2012, your total payment from Medicare and Medicaid combined should be no less than the lower of the Medicaid rate or the Medicare rate for the drug. 

HHSC is researching the quickest short-term and best long-term solution to reinstating correct payment for Medicare Part B co-insurance for those prescription drugs that are a benefit of Medicaid.  We will notify pharmacies as soon as possible with specific instructions for resubmitting previously-processed claims and for submitting future prescription claims.  As long as your claim is otherwise payable (e.g., eligible Medicaid client, covered drug, etc.) you will receive the appropriate payment from HHSC. 

While HHSC develops a process to allow you to submit/resubmit crossover claims, we ask you to continue to furnish access to critical and life-saving medications to your most vulnerable patients.  Please keep in mind that you may not request payment directly from your Medicaid customers.

If you previously submitted your crossover claims to the Texas Medicaid Healthcare Partnership, you may be able to submit claims immediately for some of your dual-eligible patients to the Vendor Drug Program (VDP) Pharmacy claims system.  If you submit an Eligibility Verification transaction to the VDP system (through your point-of-sale system) and get an affirmative response, then you can submit your prescription drug claim to the VDP system.  Please contact the VDP Pharmacy Resolution Help Desk for assistance, at 1-800-435-4165.

Medicaid Coverage of Co-Insurance for Medicare Part B Immunosuppressant Drugs Instructions for Billing Part B Co-Insurance

April 20, 2012

On March 30, the Vendor Drug Program (VDP) notified pharmacy providers about a change in reimbursement for claims submitted to Medicaid as the secondary payer after Medicare Part B had paid its share ― also called “crossover claims” (this notice is available online at txvendordrug.com/news/current-news.shtml).  This change caused some crossover claims for immunosuppressant and other Part B drugs to reject or receive a response of a $0 payment. The notification stated that these claims may be eligible for reimbursement.

Beginning April 16, pharmacies should begin submitting claims for Medicare Part B co-insurance, for those prescription drugs that are a benefit of Medicaid, directly to VDP and not TMHP.  This includes claims for Part B covered drugs for Qualified Medicaid Beneficiary (QBM) clients.  If you previously submitted a claim to TMHP between January 1, 2012 and April 15, 2012, and received a rejection or a response of a $0 payment, you can resubmit those claims to TMHP after May 1.  You may submit claims only to TMHP or VDP; you may not submit to both.

Claims submitted to VDP must be billed with the National Drug Code (NDC), not the Healthcare Common Procedure Coding System (HCPCS) number.  The NDCs submitted must be included in the Medicaid formulary.  Pharmacies should also ensure they submit the proper fields in the “Coordination of Benefit” (COB) segment.  The COB segment must include the disposition of the claim after submission to Medicare, including any amount paid.  Please refer to the Vendor Drug payer sheets at txvendordrug.com/downloads/ for specific requirements.  If you receive a rejection when attempting to bill VDP, please call our Pharmacy Resolution Help Desk at 1-800-435-4165 for assistance.

Vendor Drug will reimburse up to the maximum payable amount.  If the amount paid by Medicare is greater than Vendor Drug’s payable amount, Vendor Drug will pay the claim at zero dollars.  Pharmacies may not request payment directly from Medicaid customers.

Pharmacy Continuing Education

March 15, 2012

Pharmacies contracted with Vendor Drug are in a unique position to help Medicaid recipients with their pharmacy benefits. It’s important for pharmacy staff to know what pharmacy items that Medicaid pays for, which products require prior authorization, and who to contact with claim processing questions. Our website has more about these and other initiatives and reminders:

Suggestions for Pharmacies During Managed Care Transition

March 2, 2012

To assist and educate pharmacies with questions and issues related to the implementation of the Medicaid and CHIP transition to managed care, the Pharmacy Resolution Help Desk reports the following trends:

  • When a claim is submitted for a Medicaid or CHIP managed care client, the rejection will include the name of the client’s managed care plan in the “Additional Message Information” field (526-FQ) so they can bill the appropriate payer.  Pharmacies should contact their technical support or software provider to ensure they can see this field.
  • Chain pharmacy corporate offices should provide the proper education to their staff on how to access this website through store intranet sites so pharmacy staff may take full advantage of the services provided.  For this managed care transition this means tools that will provide the name of the managed care plan and how to bill claims.  Other resources include the Preferred Drug List and online searches for drug, doctor, and pharmacy.

Eligibility Verification Tools

February 24, 2012

Pharmacies have multiple methods available to verify whether a client is eligible to receive Medicaid or CHIP pharmacy services through either the Vendor Drug Program or a managed care health plan.  These tools should be used in conjunction with the managed care resources available to pharmacy staff and utilized before contacting the Vendor Drug Program Pharmacy Resolution Help Desk about any eligibility or managed care enrollment issue.  More on Eligibility Verification Tools.

Co-payments to Increase for Some CHIP Recipients

February 17, 2012

Effective March 1, 2012, the co-pay level for some recipients enrolled in the Children’s Health Insurance Program (CHIP) will increase for generic and brand name prescription drugs.  The co-pay amount due is returned in “Patient Pay Amount” (Field 5Ø5-F5) on the paid response.  Recipients and health plans have been notified of this change.

Families with incomes above 150 percent of the federal poverty level will see their co-payments for generic prescriptions drugs increase from $8 to $10.  For brand-name prescriptions drugs, the co-pay will increase from $25 to $35.

Please Note: After March 1, the designation of a drug as generic or brand may vary between managed care plans.  Therefore, the co-pay amount may vary for the same drug for clients in different plans.

Preferred Drug List Changes effective January 25, 2012

January 24, 2012

The Texas Health and Human Services Commission Vendor Drug Program will implement changes to the Medicaid Preferred Drug List (PDL) on Wednesday, January 25, 2012.  The PDL includes the Cough/Cold and Prenatal Vitamins list.  Pharmacies should never automatically switch a preferred brand medication to a non-preferred generic equivalent NDC.  This is most common with cough and cold preparations.

Please note that there are some brand name products designated as “preferred” within a therapeutic category for which there are generically equivalent products available. Two examples in the current Preferred Drug List are Zyprexa and Toprol XL.  The branded drugs in these cases provide the best value to the state, after rebates. These drugs are preferred and require no prior approval or Brand Name Necessary prescription.  The generic counterparts are non-preferred and require a prior authorization.  Pharmacies should never automatically switch a preferred medication to a non-preferred generic product requiring prior authorization or require a Brand Name Necessary prescription.  In instances when a brand name drug is on the formulary but the generic equivalent is not, a Brand Name Necessary prescription is not required.

The PDL also is available on the Epocrates drug information system, which provides access to the list from your digital handheld devices.  The system also provides clinical information, including a drug monograph, dosing and warnings.  To learn more about this service, please visit txvendordrug.com.

High-Volume Pharmacies to Educate Employees about Fraud

January 2, 2012

Federal law requires all providers and other entities that receive or make annual Medicaid payments of $5 million or more to educate their employees, contractors, and agents about fraud and false claims laws and the whistleblower protections available under those laws.  To learn more please visit the Texas Medicaid website.

Prescriber NPI Will Be Accepted October 12, 2011

November 1, 2011

On Wednesday, October 12, the Vendor Drug Program began accepting either the prescriber’s 5-character state license number or 10-digit National Provider Identifier (NPI) on all billing requests.  Since that time, the Pharmacy Resolution Help Desk reports an increase in rejections related to how pharmacies are submitting prescriber identifier numbers:

  • Prescriptions written by nurse practitioners and physician assistants must be submitted using the license number or NPI of the supervising physician.
  • Prescriptions written by interns and residents may be submitted using the license number or NPI of the supervising physician.  They may also use the license number or NPI of their training institution as verified by the Vendor Drug Program.
  • If your claim rejects with error code “EZ”, please ensure you are submitting the correct combination of ID number and qualifier in "Prescriber ID Qualifier" (Field 466-EZ) and "Prescriber ID" (Field 411-DB).  Other qualifier values are not supported and will cause the claim to reject. Please refer to payer specification documents within the Pharmacy Provider Procedure Manual for transaction requirements.
  • If you submit your claim with the NPI but receive error code “71” or “56”, please attempt to resubmit with the state license number (and appropriate qualifier).  If your pharmacy software does not allow you to submit the state license number, please contact your software provider.

Prescriber NPI numbers are available online, and claims will reject if the submitted NPI is not on file.  If you have any questions about using the NPI please contact the Pharmacy Resolution Help Desk.

The New Your Texas Benefits Medicaid Card

August 29, 2011

This month, HHSC began issuing new Medicaid ID cards to Texas Medicaid clients. The new ID, called the Your Texas Benefits Medicaid card, is a plastic, magnetic-striped card that replaces the paper Medicaid ID (Form 3087).  Texas Medicaid clients will present this card at the pharmacy when picking up or filling new prescription medications.

Some Your Texas Benefits Medicaid cards have QMB printed in the upper-right corner.  This abbreviation denotes clients with Qualified Medicare Beneficiary benefits that do not include prescription coverage.  Do not submit pharmacy claims for payment for clients with the QMB notation on their card.  Claims submitted for these clients will reject because the client does not have prescription coverage through Medicaid.

Pharmacists and other pharmacy staff can use one of the existing Vendor Drug eligibility verification tools to obtain out-patient pharmacy eligibility and prescription benefits data for any client.

Pharmacies Invited to Join Medicaid/CHIP Managed Care Networks

August 25, 2011

By March 2012, the majority of Medicaid and Children’s Health Insurance Program (CHIP) clients will receive their pharmacy benefits from a managed care plan.  HHSC tentatively awarded contracts to several Managed Care Organizations (MCOs) that have teamed up with Pharmacy Benefit Managers (PBMs) to provide benefits in each service delivery area.  Managed Medicaid programs are called STAR, STAR+PLUS, STAR-MRSA, and STAR Health – out-patient drugs will be a benefit of each program and CHIP.

The names of all enrolled Medicaid pharmacies have been provided to the MCOs.  They must consider all Significant Traditional Providers (as found in the link provided below) enrolled pharmacy providers when building their provider network.  Many Texas pharmacies have already been contacted by the MCOs or their PBM.

As HHSC awards managed care contracts, those plans will work to execute contracts with providers.  HHSC encourages pharmacies to engage in contract discussions with the selected MCOs/PBMs.  Please take the time to understand the financial and administrative terms and conditions that are offered.  HHSC wants to maintain a robust provider network in every service delivery area.

To find additional information about the tentative MCO contract awards and information on the procurement, visit the HHSC Business Opportunities site.  Click on the “RFP Documents” link on the same page to see maps of the service delivery areas for each of managed Medicaid programs.

More information about these changes is in the recent edition of the Rx Update.

Medicare D Limited Income NET Program

January 1, 2010

Effective January 1, 2010, Humana began administering the Limited Income NET Program on behalf of the Centers for Medicare & Medicaid Services (CMS). This program allows certain individuals with the Low Income Subsidy (LIS) to receive immediate need coverage at the point-of-sale if they are not already enrolled into a Medicare Part D plan. Additionally, CMS will temporarily enroll newly identified individuals that are dually eligible for both Medicare and Medicaid into the Limited Income NET Program contract (contract number X0001). This allows for a smoother transition as CMS auto-enrolls the individual into standard Medicare prescription drug plans. Limited Income NET Program replaces the WellPoint Point-of-Sale Facilitated Enrollment (POS FE) process. Pharmacy providers should submit an Eligibility Verification (E1) request to Medicare to retrieve appropriate plan processing information.