The Vendor Drug Program real-time point-of-sale claim system processes outpatient pharmacy claims, verifies state assistance program eligibility, and sends weekly payment file to the Texas Comptroller of Public Accounts to process payment.

  • Outpatient pharmacy claims are processed for fee-for-service Medicaid, the Children with Special Health Care Needs (CSHCN) Services program, the Kidney Health Care (KHC) program, and Healthy Texas Women (HTW) program.
  • The system performs over 100 separate edits, including validation of the submission format; pharmacy, prescriber, and product; identifying prior authorization requirements or other known insurances; and calculating reimbursement.
  • The system responds with information regarding the person’s eligibility, the program’s allowed payable amount, applicable prospective drug utilization review messages, and applicable error codes and messages.  
  • The system allows pharmacy staff to query program eligibility, prescription benefits, and managed care enrollment status when applicable.  Refer to the Eligibility chapter to learn more about real-time eligibility verification.