Non-contracted pharmacies and out-of-state claims

Any active Texas Medicaid or CHIP recipient maintaining state residence is eligible for services provided outside the state.  For the Vendor Drug Program to consider payment, the service must have been prescribed by an approved practitioner*, dispensed by an approved pharmacy provider, and the medication must be a reimbursable product on our drug formulary.

Pharmacies located within 30 miles or less from the Texas state border should refer to our Pharmacy Application Process.

Pharmacies located more than 30 miles from the Texas state border line should submit the Agreement for Pharmacies Located Outside of Texas, along with the following information:

  1. A copy of your state pharmacy license
  2. A copy of the prescription signed by the physician*
  3. A copy of the pharmacy’s prescription label
  4. A copy of the Certification Regarding Debarment

Please note contracts are not granted to these applicants unless additional benefits to the recipient are established.  The completed and signed forms should be faxed and then mailed (with original signatures) to the Medicaid/CHIP Contract Management unit.

The provider certifies that the information and claims submitted will be true and accurate, complete, and that such information can be verified by source documents. The pharmacy must comply with all applicable federal laws and all laws of the state in which it resides. In addition, the pharmacy must retain all pertinent records, including but not limited to prescription documents, medication invoices, and medication acquisition documents for a minimum of three years and ninety days after the end of the federal fiscal year in which the services were provided.

Once the pharmacy is approved for participation, the pharmacy may submit their claims online through the Vendor Drug point of sale claim processing system.  Pharmacy providers and/or their software vendor should refer to our Pharmacy Provider Procedure Manual for requirements regarding system software, timely filing limits, monthly prescription limits, and allowable refills and quantities.  Questions pertaining to claims processing and payment should be directed to our provider-only Pharmacy Resolution Help Desk at 800-435-4165.

* If the prescribing physician is located outside Texas, please ensure the following information is noted either on the prescription or included as an additional attachment: the physician’s name, state license number, National Provider Identifier (NPI), address, county, city, state, and telephone/fax number. 

Claims are processed for payment weekly.  By law, payments can only be made to the provider of services.  No payments will be made directly to the Medicaid or CHIP client.