HHSC provides specific vitamin and mineral products as a pharmacy benefit to clients 20 years of age or younger and enrolled in Medicaid, and the CSHCN Services Program. The products are also available through the Medicaid Comprehensive Care Program (CCP) as a medical benefit.
Pharmacies are not required to enroll in the CCP or as a Medicaid durable medical equipment (DME) provider to supply these products. Pharmacies already enrolled as Medicaid CCP or DME providers can submit claims as a pharmacy benefit or medical benefit. Contact the Texas Medicaid and Healthcare Partnership (TMHP) for instructions about submitting medical claims.
Prescribing providers enrolled with Medicaid as DME providers should continue to submit claims for traditional Medicaid clients to TMHP. Refer to the Children's Services Handbook of the Texas Medicaid Provider Procedures Manual (tmhp.com/resources/provider-manuals/tmppm).
A list of products is available through the Formulary search (txvendordrug.com/formulary/formulary-search). You can search by product name, the 11-digit NDC, or click the "vitamin and mineral" checkbox. Additional filters are available to find products payable by each program. A list of products and their associated condition are below.
The Medicaid CCP may pay for products not available on the search for clients enrolled in traditional Medicaid for particular medical conditions.
|Vitamin or Mineral||Condition|
|Beta-carotene||Vitamin A deficiency, Cystic fibrosis, Disorders of porphyrin metabolism, Intestinal malabsorption|
|Biotin||Biotin deficiency, Biotinidase deficiency, Carnitine deficiency|
|Calcium||Calcium deficiency, Disorders of calcium metabolism, Chronic renal disease, Pituitary dwarfism, isolated growth hormone deficiency, Hypocalcemia and hypomagnesemia of the newborn, Intestinal disaccharidase deficiencies and disaccharide malabsorption, Allergic gastroenteritis and colitis, Hypocalcemia due to use of Depo-Provera contraceptive injection|
|Iodine||Iodine deficiency, Simple and unspecified goiter, and nontoxic nodular goiter|
|Iron||Disorders of iron metabolism, Iron deficiency anemia, Sideroachrestic anemia|
|Magnesium||Magnesium deficiency, Hypoparathyroidism|
|Multi-minerals||Other and unspecified protein-calorie malnutrition|
|Multi-vitamins||Cystic fibrosis, Other and unspecified protein-calorie malnutrition|
|Phosphorus||Disorders of phosphorus metabolism|
|Trace elements||Mineral deficiency|
|Vitamin A (retinol)||Vitamin A deficiency, Intestinal malabsorption, Disorders of the biliary tract, Cystic fibrosis|
|Vitamin B1 (thiamin)||Vitamin B1 deficiency, Disturbances of branched-chain amino-acid metabolism (e.g., maple syrup urine disease), Disorders of mitochondrial metabolism, Wernicke-Korsakoff syndrome|
|Vitamin B2 (riboflavin)||Vitamin B2 deficiency, Disorders of fatty acid oxidation, Riboflavin deficiency, ariboflavinosis, Disorders of mitochondrial metabolism|
|Vitamin B3 (niacin)||Vitamin B3 deficiency, Disorders of lipid metabolism, (e.g., pure hypercholesterolemia)|
|Vitamin B5 (pantothenic acid)||Vitamin B5 deficiency|
|Vitamin B6 (pyridoxine, pyridoxal 5phosphate)||Vitamin B6 deficiency, Sideroblastic anemia|
|Vitamin B12 (cyanocobalamin)||Vitamin B12 deficiency, Disturbances of sulfur-bearing amino-acid metabolism (e.g., homocystinuria and disturbances of metabolism of methionine), Pernicious anemia, Combined B12, and folate-deficiency anemia|
|Vitamin C (ascorbic acid)||Vitamin C deficiency, Anemia due to disorders of glutathione metabolism, Disorders of mitochondrial metabolism|
|Vitamin D (ergocalciferol)||Vitamin D deficiency, Galactosemia, Glycogenosis, Disorders of magnesium metabolism, Intestinal malabsorption, Chronic renal disease, Cystic fibrosis, Disorders of phosphorus metabolism, Hypocalcemia, Disorders of the biliary tract, Hypoparathyroidism, Intestinal disaccharidase deficiencies, and disaccharide malabsorption, Allergic gastroenteritis, and colitis|
|Vitamin E (tocopherols)||Vitamin E deficiency, Inflammatory bowel disease (e.g., Crohn's, granulomatous enteritis, and ulcerative colitis), Disorders of mitochondrial metabolism, Chronic liver disease, Intestinal malabsorption, Disorders of the biliary tract, Cystic fibrosis|
|Zinc||Zinc deficiency, Wilson's disease, Acrodermatitis enteropathica|
A prescription is required for HHSC to process pharmacy claims for clients enrolled in fee-for-service Medicaid and the CSHCN Services Program.
HHSC does not require the TMHP CCP Prior Authorization Request Form for products dispensed by a pharmacy. Refer to the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook of the Texas Medicaid Provider Procedures Manual (tmhp.com/resources/provider-manuals/tmppm) for quantity guideline criteria.
Claims for traditional Medicaid do not count towards a client's three prescription-per-month limit.
HHSC sets the reimbursement rate at the Average Wholesale Price minus 10.5 percent, minus 8 percent. Pharmacies do not receive a dispensing fee or delivery incentive.
Multi-ingredient compound claims submitted with vitamin or mineral products are not payable. HHSC may consider some compound claims for coverage through CCP.
Claims are limited to a 30-day supply. Pharmacy providers should contact HHSC for liquid formulations greater than this limit. Pharmacies should not dispense refills until the client uses 100% of the supply. Prescriptions are valid for six months after the date written.
The pharmacy must acknowledge the prescribed product is for a medically accepted indication according to the current vitamin and mineral policy by submitting the following values:
|Field Name||Field Number||Value|
|Prior Authorization Type Code||461-EU||8 (Payer Defined Exemption)|
|Prior Authorization Number Submitted||463-EV||826 (Medically accepted indication for vitamins and minerals)|
HHSC does not require the DME Certification and Receipt Form (TMHP Form F00018) for pharmacy claims.
Pharmacies submit claims for clients enrolled in Medicaid managed care and CHIP to the client's MCO. Pharmacies providers should contact the client's specific MCO for details.