HHSC covers mosquito repellents year-round for the prevention of the Zika virus and other related mosquito-borne diseases for clients enrolled in the following programs:
- Children's Health Insurance Program (CHIP) and CHIP-Perinatal
- Children with Special Health Care Needs (CSHCN) Services Program
- Healthy Texas Women program (HTW)
HHSC selects products based on guidance from the Centers for Disease Control and Prevention (CDC). Products include the recommended amount of the active ingredient DEET, IR3535, oil of lemon eucalyptus, or Picaridi effective against the Zika virus.
Refer to the Formulary search (txvendordrug.com/formulary/formulary-search) for a list of products. Users can search by product name, the 11-digit NDC, or click the "mosquito repellent" checkbox for a list of all products.
Download the Mosquito Repellent Benefit Information to display information about the benefit in pharmacies or doctor offices. For more information about the Zika virus, refer to the following resources:
- Texas Department of State Health Services (texaszika.org)
- Zika Medicaid Benefit (hhs.texas.gov/services/health/zika-medicaid-benefit)
- CDC: Zika Virus (cdc.gov/zika)
Clients eligible for the benefit include the following demographics:
- Females ages 10-55 years old
- Pregnant females of any age
- Males ages 14 and older
HHSC requires a prescription for all clients. Contact the client's health care provider to obtain a prescription for mosquito repellent.
Coverage of mosquito repellents is limited to two cans or bottles per calendar month. Pharmacies should dispense only one can or bottle per fill, with one optional refill available per calendar month.
Mosquito repellent claims do not count against a person's monthly three-prescription limit for people enrolled in traditional fee-for-service Medicaid.
Pharmacies will require a prescription from a valid healthcare provider before dispensing mosquito repellent to clients enrolled in Medicaid.
Other Medicaid benefits available in response to Zika virus prevention include oral contraceptives and long-acting reversible contraceptive products that help to prevent pregnancy. These are available as a Medicaid benefit to eligible individuals. Other covered benefits include family planning services, diagnostic testing, targeted case management, physical therapy, long-term services and support, acetaminophen, and oral electrolytes for Zika virus symptoms, and potential coverage for additional ultrasounds for pregnant women.
Claims for mosquito repellent must use the client’s provider National Provider Identifier (NPI) as the prescriber NPI on the claim. HHSC converted each product's 12-digit universal product code (UPC) into an 11-digit NDC for claims submission. HHSC identifies mosquito repellents as a generic medication. Pharmacists have the authority to fill the prescription with any covered product unless the prescriber has stated "do not substitute" to specify the active ingredient.
The "Unit of Measure" field (600-28) determines the "Quantity Dispensed" field (442-E7). When processing mosquito repellent claims, pharmacy providers should submit the standard unit in the "Unit of Measure" field. For example, the pharmacy should submit a 170-gram bottle of mosquito repellent with a quantity of 170.
HHSC expects a can of repellent to last 15 days or more and recommends pharmacy providers submit a 15-day supply.
Pharmacy providers may request manual overrides of claims clients outside the eligibility requirements of pregnant women.
- Contact the HHSC Pharmacy Benefits Access Help Desk for clients enrolled in traditional Medicaid, CSHCN, and HTW programs
- Pharmacy providers should contact the client's specific MCO for details
Pharmacies are required to submit their usual and customary cost for the items.
The traditional Medicaid reimbursement is the usual and customary price to the public or up to a maximum of $6.50 per can or bottle of mosquito repellent (inclusive of product cost and dispensing fee), with the total calendar month maximum of $13.00. Products are not eligible for delivery fees or incentive fees.
Reimbursement may vary between MCOs but may not exceed $6.50 per can or bottle.