All outpatient pharmacy and clinician-administered drug claims for all stateadministered drug rebate programs are sent to the VDP Drug Rebate System for invoicing.
VDP invoices drug manufacturers for all claims, not excluded because of the 340B program, where the state has paid any amount of money, including co-pay, coinsurance, or any other payment type. Claims or amounts paid for dual eligible patients, either directly by the state or through a Medicaid MCO, are also invoiced.
Outpatient pharmacy drug claims submitted with a date of service on or after January 1, 2014, will only be excluded from the drug rebate system invoicing process if they are submitted with a “2Ø” in Submission Clarification Code (Field 42Ø-DK). It is the responsibility of the covered entity and their contracted pharmacies to correctly report claims filled with 340B stock for 340B-eligible patients to ensure rebates are not collected for these drugs.
For outpatient clinician-administered drug claims, Texas HHS uses the modifier “U8” on claims and encounters, as well as HRSA’s Office of Pharmacy Affairs (OPA) Medicaid Exclusion file to identify Texas providers that have been added or deleted. Refer to the "Medicaid Exclusion File" page on the federal HHS website.
For claims and encounters with a paid date on or after April 1, 2017, only medical claims and encounters with the U8 in the modifier field will be excluded from Texas HHS’s rebate invoicing. Texas invoices drug manufacturers for all other claims where the state has paid any amount of money, including co-pays, co-insurance, capitated rates, or any other payment type. Claims or amounts paid for people that are dual eligible, either directly by the state or through a Medicaid managed care health plan, are also invoiced.