Expansion of Pharmacy Benefit for Pharmacist Reimbursable Services Begins Sept. 1

Published on
August 27, 2020

On Sept. 1, 2020, HHSC will expand the Medicaid and CHIP benefit to allow pharmacists to administer certain medications in a pharmacy setting, including the administration of:

  • certain long-acting anti-psychotics
  • opiate dependence treatments and emergency treatment for known or suspected opioid overdoses
  • flu vaccines

These products were added to the Medicaid and CHIP formularies. Pharmacies must be reimbursed for the ingredient cost, administration fee, and applicable dispensing fee for each claim processed. Reimbursement for administration of certain long-acting injectable anti-psychotics and opioid antagonists:

  • Ingredient cost
  • Administration fee
  • Dispensing fee

Reimbursement for administration of flu vaccines:

  • Ingredient cost
  • Administration fee

To prepare pharmacies for changes to the claims submission process an addendum to the NCPDP B1 Transaction Billing Request Payer Sheet is available showing changes to three existing fields in the Drug Use Review/Professional Pharmacy Service segment and addition of one new field to the Pricing segment. Pharmacies should refer to the addendum for more information on how this change impacts claims processing. VDP will revise the full B1 payer sheet upon implementation.

Pharmacy staff can also reference the Drug Policy chapter of the Pharmacy Provider Procedure Manual.