Texas CHIP/Medicaid Drug Vendor Program News

System Maintenance to Interrupt Payment Cycle

September 30, 2011

The Vendor Drug Program point-of-sale claim system will undergo two separate maintenance periods beginning Thursday, October 13, 2011.  Between midnight Thursday, October 13, 2011, to 2:00 a.m. Friday, October 14, 2011, pharmacies will be unable to submit claims.

Because of this maintenance, the weekly payment cycle will run at midnight on Wednesday, October 12, 2011, instead of at midnight Thursday, October 13, 2011.  Pharmacy payments dated October 17, 2011, will contain claims for six days rather than the usual seven-day claim cycle.  This affects all claims for Medicaid, CHIP, CSHCN, and KHC claims.  The following week’s payment, dated October 24, 2011, will contain an eight-day claim cycle.  Subsequent payments will be back on the usual seven-day cycle beginning with payment date October 31, 2011.  View a full schedule (PDF) of the affected payment cycles.

The second maintenance window will begin Saturday, October 15, 2011.  Between midnight Saturday, October 15, 2011, to 8:00 a.m. Sunday, October 16, 2011, pharmacies will be unable to submit claims

Dispensing Fee To Be Reduced By 85 Cents

August 9, 2011

The Texas Health and Human Services Commission will implement new payments for pharmacies participating in the Vendor Drug Program based on the funds appropriated by the Texas Legislature.  Effective September 1, 2011, your dispensing fee for each Medicaid prescription will be reduced by 85 cents.

Your payment for a legend drug prescription will be determined by adding $6.50 (previously $7.35) to the estimated acquisition cost (EAC) of that drug and dividing the sum by 0.9804. An additional 15 cents will be added to that amount if your pharmacy has been certified as providing free delivery service to Medicaid clients. Another 50 cents will be added to that amount if your pharmacy dispenses a premium preferred generic. For example, if the EAC cost of a drug is $10, your payment will be calculated in the following way:

• $10 plus $6.50 equals $16.50.
• $16.50 divided by 0.9804 equals $16.82.
• If you have a delivery agreement, add 15 cents, which equals $16.97
• If you used a premium preferred generic, add 50 cents for a total reimbursement of $17.47.

If your true usual and customary (U&C) price for this item is less than the amount calculated above, you will be paid your U&C price. Non-legend drugs (OTC) will be reimbursed using the calculated price, your true U&C price, or one and one-half times the product cost, whichever is lowest. Please remember to submit your true U&C price for all claims. Note: Providers who are currently required to submit the actual acquisition cost of the drug product must continue to do so.

Removal of Cough and Cold Products from Formulary

May 6, 2011

On May 4, 2011, the Centers for Medicare & Medicaid Services (CMS) notified the Vendor Drug Program that the following active cold, cough, and allergy National Drug Codes (NDC) are unapproved new drugs within the meaning of section 201(p) of the Federal Food, Drug and Cosmetic Act.  These NDCs should not be marketed without appropriate FDA approval and are subject to enforcement action.  The NDCs listed below do not meet the definition of a covered out-patient drug as defined in Section 1927(k) of the Social Security Act and are no longer eligible for inclusion in the rebate program.  Therefore, these products have been deleted from the Vendor Drug formulary effective Thursday, May 5, 2011.

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.