3.1 Fee for Service
Claims for people enrolled in Medicaid and the CSHCN Services Program are submitted to the Vendor Drug Program.
3.1.1 Prescription Guidelines
A written, faxed, or electronic prescription is required with the following information:
- Person’s name and address
- Name, strength, and quantity of product prescribed
- Date written
- Directions and indications for use
- To expedite processing, prescribing providers are encouraged to include diagnosis on prescription
Faxed prescriptions must include the name of the designated agent who transmitted the fax or electronic order, the telephone number of the prescribing provider, and a statement the prescription was faxed
The "CCP Prior Authorization Request form" is not required for vitamins and minerals dispensed through a pharmacy.
3.1.2 Claim Submission
Multi-ingredient compound claims submitted with vitamins or minerals are not payable through VDP. Some compound claims may be considered for coverage through CCP.
Claims are limited to a 30-day supply. Pharmacy staff should contact the Pharmacy Benefits Access Help Desk for liquid formulations more than this limit. Refills may not be dispensed until 100% of the supply has been used. Prescriptions are valid for six months after the date written.
Pharmacy staff must acknowledge the prescribed product is for a medicallyaccepted indication according to the current vitamin and mineral policy by submitting the values in Table 1.
VDP Vitamin and Mineral Medical Certification Codes
|Field Name||Field Number||Value|
Prior Authorization Type Code
“8” (Payer Defined Exemption)
Prior Authorization Number Submitted
“826” (Medically accepted indication for vitamins and minerals)
3.1.3 Prescription Limits
- Claims for traditional Medicaid do not count towards a person’s three prescription-per-month limit.
- Pharmacies are not paid a dispensing fee or delivery incentive.
- Pharmacies requiring signatures to pick up prescriptions should require a signature for people picking up home health supplies.
- The "DME Certification and Receipt Form" is not required.
3.2 Managed Care
Pharmacy claims for people enrolled in Medicaid managed care or CHIP are submitted to the person’s managed care organization (MCO). Pharmacy staff must work with the MCO's pharmacy benefit manager to determine the billing requirements, reimbursement rates, and coverage limitations for these products.
Refer to the Pharmacy MCO Assistance Chart (PDF) for the pharmacy call center phone numbers for each MCO, or refer to the Managed Care section in the Contact chapter of this manual to contact the appropriate MCO in your area.