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Vendor Drug Program
    • About the Program
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    • Pharmacy Search
    • Prescriber Search
    • 340B Providers
    • Formulary
    • Formulary Search
    • Provisional Formulary Search
    • Clinician-Administered Drugs
    • Clinical Prior Authorizations for Managed Care
    • Clinical Prior Authorizations for Traditional Medicaid
    • Hepatitis C
    • Preferred Drugs
    • Prior Authorization
    • Respiratory Syncytial Virus Treatment
    • Shortages
    • Specialty Drugs
    • Drug Utilization Review Board
    • DUR Board Annual Disclosures
    • DUR Board Documents
    • DUR Board Members
    • Resources
    • Data Files
    • Documents
    • Forms
    • Managed Care
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    • Outreach and Education
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Breadcrumb

  1. Home
  2. About
  3. Manuals
  4. Pharmacy Provider Procedure Manual
  5. P-1. Introduction
  6. Rule and Statute Information
    • Search this manual
    • P-1. Introduction
      • Index
      • Mission
      • Communication
        • Email Notification Service
        • Facsimile Broadcast Service
      • History
      • Outreach and Education
        • Continuing Education Modules
        • Downloadable Outreach and Education Materials
        • Quick Courses
        • TMHP Learning Management System
      • Programs
      • Rule and Statute Information
      • HIPAA Privacy Notice
    • P-2. Contact Information
      • Vendor Drug Program Contacts
        • VDP Clinician-administered Drug Administration Contact
        • VDP Pharmacy Claim Processing Contact
        • VDP Pharmacy Enrollment and Support Contact
        • VDP Prior Authorization Contact
          • Texas Prior Authorization Call Center - Clinical Prior Authorization Contact
          • Texas Prior Authorization Call Center - Non-preferred Prior Authorization Contact
        • VDP Refund Contact
        • VDP Third-party Recovery Contact
      • Managed Care Organization Contacts
        • MCO Client Eligibility Contact
        • MCO Complaint Contact
        • MCO Pharmacy Claim Processing Contact
        • MCO Pharmacy Network Contact
        • MCO Pharmacy Prior Authorization Contact
        • MCO Third-party Recovery Contact
      • Texas Health and Human Services Contacts
        • Fraud, Waste and Abuse Reporting
      • Children with Special Health Care Needs Services Program Contacts
        • CSHCN Services Program Eligibility Verification Contact
        • CSHCN Services Program Pharmacy Claim Processing Contact
        • CSHCN Services Program Prior Authorization Contact
      • Kidney Health Care Program Contacts
        • KHC Program Claim Pharmacy Claim Processing Contact
      • Texas Department of State Health Services Contacts
        • DSHS Immunization Program Contact
      • Texas Medicaid and Healthcare Partnership Contacts
        • TMHP Client Help Line
        • TMHP Provider Enrollment
        • TMHP Resources
      • Medicare Contacts
        • Facilitated Enrollment
        • Limited Income NET Program
      • Centers for Medicare and Medicaid Services Contacts
        • CMS Drug Pricing Contact
        • CMS National Plan and Provider Enumeration System Contact
    • P-3. Enrollment
      • Index
      • Enrollment Process
      • Non-pharmacy Enrollment
        • Comprehensive Care Program Enrollment
        • Durable Medical Equipment Provider Enrollment
      • Operations
        • Delivery Incentive
          • Fee-for-service Delivery Incentive
          • Managed Care Delivery Incentive
        • Direct Deposit
        • High-Volume Fraud Education
        • License Information
        • Maintaining Enrollment
        • Pharmacy Discount Membership Programs
        • Records Retention
        • Revalidation
        • Software Vendor
        • Termination for Inactivity
        • Third-Party Discount Plans
      • 340B Drug Pricing Program Enrollment
    • P-4. Managed Care
      • Managed Care Clinical Prior Authorization
      • Managed Care Complaints
      • Managed Care Formulary Management
      • Managed Care Pharmacy Participation
      • Managed Care Programs
      • Managed Care Search
    • P-5. System Requirements
      • P-5.1. Pharmacy Claims System
      • P-5.2. Switch Companies
      • P-5.3. Claim Format
        • 5.3.1. NCPDP Transactions
          • Claims Billing (B1) Transaction
          • Claims Billing Reversal (B2) Transaction
          • Eligibility Verification (E1) Transaction
        • 5.3.2. NCPDP Transaction Segments
        • 5.3.3. NCPDP Transaction Segment Data Elements
      • P-5.5. Edits
        • Timely Filing Limits
      • P-5.6. E-prescribing
    • P-6. Eligibility
      • Identification Numbers
        • Medicaid
          • Medicaid Copayment Information
          • Medicaid Managed Care Eligibility
          • Medicaid Presumptive Eligibility
          • Temporary Medicaid Eligibility Verification
        • Children with Special Health Care Needs Services Program Eligibility
          • CSHCN Copayment Information
          • CSHCN Identification Form
        • Children’s Health Insurance Program Eligibility
        • Healthy Texas Women Program Eligibility
        • Kidney Health Care Program Eligibility
          • KHC Copayment Information
          • KHC Identification Card
        • STAR Health Eligibility
      • Pharmacy Verification of Eligibility
        • Real-time Eligibility Verification
          • Eligibility Verification (E1) Transaction
        • Your Texas Benefits Medicaid Card
    • P-7. Coordination of Benefits
      • Medicaid Coordination of Benefits
        • Medicaid With Other Insurance
          • Texas Pharmacy Third Party Insurance Call Center
          • Third-party Contact Guidance
        • Medicaid with Medicare
        • Medicaid with Medicare Part B
        • Medicaid with Medicare Part D
          • Opting out of Medicare Part D
          • Extra Help with Medicare Prescription Drug Plan Costs
          • Limited Income NET Program
          • Medicare Facilitated Enrollment
      • CSHCN Services Program Coordination of Benefits
        • CSHCN With Medicaid
        • CSHCN with Medicare Part B
        • CSHCN with Medicare Part D
        • CSHCN with Other Insurance
      • KHC Program Coordination of Benefits
        • KHC with Medicare Part B
        • KHC with Medicare Part D
        • KHC with Other Insurance
    • P-8. Drug Policy
      • Claim Limitations
        • Dollar Limits
        • Prescription Limits
        • Refill Authorization
        • Refill Limitations
        • Refill Too Soon Overrides
        • Refill Utilization
      • Claim Requirements
        • Days Supply
        • Dispense as Written
        • Drug Format
        • Drug Unit of Measure
        • Prescription Splitting
        • Quantity Dispensed
      • Drug Coverage
      • Drug Shortages
      • Epocrates
    • P-9. Formulary Coverage
      • Index
      • Anti-Fungal Products
      • Biosynthetic Growth Hormone Agents
      • Blood Factor Products
      • COVID-19 Oral Antivirals
      • COVID-19 Test Kits
      • COVID-19 Vaccines
      • Compound-only Drugs
      • Cough and Cold Products 
      • Cystic Fibrosis Treatment Agents
      • Diabetic Test Strips
      • Emflaza
      • Enzyme Replacement Therapy Products
      • Erectile Dysfunction Products
      • Family Planning Products
      • Hepatitis C Direct–Acting Antiviral Treatment Products
      • Home Health Supplies
      • Human Immunodeficiency Virus Products
      • Increlex
      • Influenza Vaccines
      • Insulin and Insulin Syringes
      • Kidney Transplant Drugs
      • Long-acting Injectable Products
      • Long-acting Reversible Contraception Products
      • Migraine Medications
      • Mosquito Repellents
      • Opioid Products
      • Over-the-counter Drugs
      • Oxycontin
      • Pediculosis Treatment Products
      • Peritoneal Treatment Products
      • Phosphate Binder Agents
      • Premium Preferred Generic Drugs
      • Prenatal Vitamins
      • Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitor Agents
      • Pulmonary Hypertension Drugs
      • Respiratory Syncytial Virus Treatment
      • Smoking Cessation Products
      • Specialty Drugs
      • Tramadol with Codeine
      • Vitamins and Minerals
      • Weight Management Drugs
      • Xyrem
    • P-10. Drug Utilization Review
      • Index
      • Prospective Drug Utilization Review
        • DUR Alerts
        • DUR Rejections
        • DUR Result of Service
        • OBRA 90 Requirements for Pharmacies
      • Retrospective Drug Utilization Review
      • Texas Drug Utilization Review Board
    • P-11. Prior Authorization
      • Medicaid Prior Authorization
        • Medicaid Clinical Prior Authorization
          • Fee-For-Service Clinical Prior Authorization
          • Optional Managed Care Clinical Prior Authorization
          • Required Managed Care Clinical Prior Authorization
        • Medicaid Non-preferred Prior Authorization
          • Preferred Drug List Process
        • Emergency Override
        • Medicaid Prior Authorization Reconsideration
        • Obtaining Prior Authorization
      • CSHCN Services Program Prior Authorization
        • CSHCN Services Program Prior Authorization Appeal Information
    • P-12. Pricing and Reimbursement
      • Drug Pricing
      • Ingredient Cost and Reimbursement Methodologies
      • Professional Dispensing Fees
    • P-13. 340B Resources
      • Index
      • 340B Participation
      • 340B Contracted Pharmacies
      • 340B Pharmacy Claim Submission
      • 340B Pharmacy Reimbursement
      • 340B Clinician-administered Drug Claim Submission
      • 340B Drug Rebates
      • 340B Responsibilities
    • P-14. Payment
      • Index
      • Payment Cycle
      • Payment Delays
      • Provider Payment Algorithms
        • Basis of Cost Determination
        • Gross Amount Due
        • Submission Clarification Code
        • Usual and Customary
      • Provider Payment Calculation
      • Refunds
    • P-15. Audits
      • Index
      • Audit Process
      • Informal Appeals
    • P-16. Drug Rebates
      • Index
      • Desk Reviews and Disputes
        • Clinician-Administered Drug Claims
        • Pharmacy Claims
    • P-17. Documents
      • Clinical Prior Authorization Documents
      • Enrollment Documents
      • Outreach and Education Documents
      • Preferred Drug Documents
    • P-18. Forms
      • Index
      • Formulary Management Forms
      • Pharmacy Enrollment Forms
      • Pharmacy Operations Forms
        • Pharmacy Claims Billing Request
      • Prior Authorization Reconsideration (Medicaid fee-for-service)
      • Prior Authorization Requests (CSHCN Services Program)
      • Prior Authorization Requests (Medicaid fee-for-service)
      • Program Management Forms

Rule and Statute Information

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HHSC is subject to federal and state rules, statutes, and regulations. Refer to citations in the Rules and Statutes Handbook.

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