Medication synchronization establishes processes for early refills to align the filling or refilling of multiple medications for a person with chronic illnesses. In accordance with the Texas Insurance Code (Chapter 1369, Subchapter J) the person, their prescribing physician, or the dispensing pharmacist may initiate the medication synchronization request.
4.5.1 Eligible Medications
A drug is eligible for medication synchronization if:
- It is listed in the Texas Drug Code Index (formulary) for Medicaid, CHIP, KHC or CSHCN Services Program
- It is used for treatment and management of chronic illnesses
- It is a formulation or dosage form able to be effectively dispensed in a medication synchronization protocol
- It must meet all prior authorization criteria applicable to the medication on the date the synchronization request is made, including clinical prior authorizations, non-preferred prior authorizations, and drug utilization review edits
- It must be within the same Generic Code Number (GCN) class as the previously dispensed prescription (the GCN class includes NDCs form different manufacturers with the same drug strength and formulation)
4.5.2 Medication Exceptions
A drug is not eligible for medication synchronization if it is one of the following:
- Schedule II controlled substance
- Schedule III controlled substance containing hydrocodone
Medications eligible for synchronization must be used to treat chronic illnesses. A chronic illness is defined as an illness or physical condition:
- Reasonably expected to continue for an uninterrupted period of at least three months, and
- Controlled, but not cured by medical treatment. This includes drugs used to treat mental health conditions and substance abuse.
184.108.40.206 VDP Processed
A synchronized claim will count as one of the three prescriptions Medicaid will pay if a person is limited. A fourth claim will reject with NCPDP error code 76 ("Plan limitations exceeded").
Pharmacy staff attest the medication is used to treat a chronic illness by submitting these values:
- “9Ø1” in the “Prior Authorization Number Submitted” field (462-EV)
- “Ø8” in the “Prior Authorization Type Code” field (461-EU)
Pharmacy staff may call the Pharmacy Benefits Access Help Desk at 1-800-4354165 for assistance.
220.127.116.11 Medicaid Managed Care and CHIP
Each MCO has an HHSC-approved process for medication synchronization for people eligible for Medicaid or CHIP. In CHIP, cost sharing or copayment amounts will be prorated. Dispensing fees will not be prorated. Pharmacy staff should contact each MCO for its medication synchronization requirements. Refer to the Pharmacy MCO Assistance Chart on the VDP website "Downloads" page for the pharmacy call center phone number for each MCO.
5.4.5. Dispensing Fees
Dispensing fees for synchronized refills claims will not be reduced or prorated.