Policy Regarding Health Benefit Plan Coverage Of Prescription Contraceptive Drugs Finalized, Implements Jan. 2024

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HB 916, 88th Legislature, amends Section 1369.102 of the Texas Insurance Code to require health benefit plans, including Medicaid fee-for-service and managed care, to follow certain quantity supply criteria for prescription contraceptive drugs. The Vendor Drug Program (VDP) published a draft version of the policy for public comment on Sept. 20, 2023. The public comment period ended on Oct. 5, 2023. The final policy below includes clarifications in response to the comments and questions VDP received. VDP will add this policy to the VDP Pharmacy Provider Procedure Manual.

  1. The prescriber may initially prescribe a one-month supply or up to a three-month supply for a covered prescription contraceptive drug. Medicaid will reimburse the pharmacy for the drug up to a three-month supply the first time the member obtains the drug. Clinically administered contraceptives are not applicable.
  2. Medicaid will reimburse up to a 12-month supply of the covered prescription contraceptive drug each time after the member obtains the same drug. VDP defines “same drug” as drugs that can be therapeutically substituted (multiple formulations, strengths, and NDCs).
  3. Members can receive one 12-month supply of a covered prescription contraceptive drug during each 12-month calendar period. This applies regardless of whether the member was enrolled in the health benefit plan the first time they obtained the drug. For example, if a member enrolls in a different health plan after obtaining the initial fill, they can receive the 12-month supply without repeating the initial fill. The MCO must implement a process that allows providers to contact the MCO’s help desk to inform whether the patient has previously taken the prescribed contraceptive.
  4. Prescribing providers can issue a prescription that covers the amount of prescription contraceptive drug a member needs for a 12-month supply. Pharmacists can only dispense a 12-month supply per calendar year. 

The Medicaid fee-for-service and managed care implementation date is Jan. 1, 2024.