Pharmacy Reimbursement & Payment
Information on how pharmacy providers are reimbursed and how to access weekly payment files.
The Vendor Drug Program reimburses contracted pharmacy providers according to the “Pharmacy (Non-DME)” fee schedule. The estimated acquisition cost is defined in the Texas Administrative Code Title 1 §355.8541 relating to Legend and Non-legend Medication and §355.8545 relating to Texas Maximum Allowable Cost. Please refer to the Drug Pricing & Reimbursement (PDF) chapter of the VDP Pharmacy Provider Procedure Manual (PPPM) to learn more.
Weekly Payment Cycle
The weekly payment cycle for all payable fee-for-service claims begins at 12:00 a.m. on Friday and ends at 11:59 p.m. the following Thursday. Payment is generally issued to providers’ financial institutions by Monday night and posted to providers accounts according to their financial institution's schedule (usually within 72 hours). Providers should take into account any federal or state holidays.
Accessing Payment Files
VDP payment registers and ASC X12N 835/5010 Health Care Payment/Advice statements are available online through the Payment File Portal (PFP). Pharmacy staff must complete and return the Electronic Remittance Advice (ERA) Authorization Agreement (PDF) to register for access. Separate remittance advice and direct deposits will be made for each program area (Medicaid, KHC, and CSHCN).
There will be one-day payment delays because of the following federal bank holidays. This affects claims paid by traditional Medicaid (fee-for-service), the Kidney Health Care (KHC) Program, and the Children with Special Health Care Needs (CSHCN) Services Program.
- Martin Luther King, Jr. Day (Monday, January 18, 2016)
- Claims submitted January 8-14 will have a payment date of January 19, with deposits available January 21.
- Presidents Day (Monday, February 15, 2016)
- Claims submitted February 5-11 will have a payment date of February 16, with deposits available February 18.
- Memorial Day (Monday, May 30, 2016)
- Claims submitted May 20-26 will have a payment date of May 31, with deposits available June 2.
- Independence Day (Monday, July 4, 2016)
- Claims submitted June 24-30 will have a payment date of July 5, with deposits available July 7.
- Labor Day (Monday, September 5, 2016)
- Claims submitted August 26-September 1 will have a payment date of September 6, with deposits available September 8.
- Columbus Day (Monday, October 10, 2016)
- Claims submitted September 30 - October 6 will have a payment date of October 11, with deposits available October 13.
- Day After Christmas (Monday, December 26, 2016)
- Claims submitted December 16-22 will have a payment date of December 27, with deposits available December 29.
- New Year's (Monday, January 2, 2017)
- Claims submitted December 23 through 29, 2016 will have a payment date of January 3, with deposits available January 5.
Pharmacy providers that want to receive their weekly payment by direct deposit must complete the Direct Deposit Authorization (form 74-176). This form is also used to change bank information, such as financial institution, account number, or cancellation of account. An account change will result in the pharmacy provider receiving paper warrants until the process is completed. Completed forms should be sent to the Medicaid/CHIP Contract Compliance.
Claims billed incorrectly, resulting in the pharmacy provider owing the Vendor Drug Program a refund, should be adjusted or recouped within 90 days of the original date of service. If it is necessary to issue a refund the pharmacy provider should refer to the instructions as noted in Section 8.5 (Pharmacy Refunds) of the Texas Pharmacy Provider Procedure Manual.