August 23, 2018
A person’s prescribed drugs used to treat chronic illnesses may be received at the pharmacy on a single, convenient day each month with medication synchronization. In accordance with the Texas Insurance Code (Chapter 1369, Subchapter J) the person, their prescribing physician, or the dispensing pharmacist may initiate the medication synchronization request to align refills.
A drug is eligible for medication synchronization if it meets the following conditions:
- It is listed in the Texas Drug Code Index (formulary) for Medicaid or CHIP.
- It is used for treatment and management of chronic illnesses.
- It is a formulation or dosage form that can be effectively dispensed in a medication synchronization protocol.
- It must meet all prior authorization criteria applicable to the medication on the date the synchronization request is made. This includes clinical prior authorizations, non-preferred prior authorizations, and drug utilization review edits.
- The original prescription must have refills.
A claim cannot be synchronized if it is a Schedule II controlled substance or a Schedule III controlled substance containing hydrocodone.
Medications eligible for synchronization must be used to treat chronic illnesses. A chronic illness is defined as an illness or physical condition that is:
- Reasonably expected to continue for an uninterrupted period of at least three months.
- Controlled but not cured by medical treatment. This includes drugs used to treat mental health conditions and substance abuse.
Dispensing fees for synchronized refills claims will not be reduced or prorated.
Initializing Medication Synchronization
Either a person, their prescribing physician, or the dispensing pharmacist may initiate the medication synchronization request to align refills.
- A synchronized claim will count as one of the three prescriptions Medicaid will pay if a person is limited. A fourth claim will reject with NCPDP error code 76 ("Plan limitations exceeded").
- To submit a synchronized claim the pharmacy should submit the following:
- “8” in the “Prior Authorization Type Code” field (461-EU)
- “9Ø1” in the “Prior Authorization Number Submitted” field (462-EV)
- By submitting these values in the claim transaction, pharmacy staff attest that the medication is used to treat a chronic illness
Medicaid Managed Care and CHIP
Each health plan has an HHSC-approved process for medication synchronization for people eligible for Medicaid or CHIP. In CHIP, cost sharing or copayment amounts will be pro-rated. Dispensing fees will not be prorated. Pharmacy staff should contact the person’s health plan for medication synchronization requirements using the contact information on the Pharmacy MCO Assistance Chart (PDF).