The Pharmacy Provider Procedure Manual (PPPM) is a comprehensive resource for pharmacy providers enrolled with the Texas Health and Human Services Commission (HHSC). The Texas Vendor Drug Program (VDP) publishes this manual with information about benefits, policies, and procedures for outpatient pharmacy claims and rebates.

The manual contains into the following sections:

1. Introduction
2. Contact Information
3. Enrollment
4. Managed Care
5. System Requirements
6. Eligibility
7. Coordination of Benefits
8. Drug Policy
9. Formulary Coverage
10. Drug Utilization Review
11. Prior Authorization
12. Pricing and Reimbursement
13. 340B Resources
14. Payment
15. Audits
16. Drug Rebates
17. Documents
18. Forms

Copyright Acknowledgments

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The mission of the Texas Vendor Drug Program is to:

• Provide statewide access to covered outpatient drugs and quality pharmaceutical care for people enrolled in Medicaid, the Children’s Health Insurance Program (CHIP), the Children with Special Health Care Needs Services Program (CSHCN), the Healthy Texas Women Program (HTW), and the Kidney Health Care Program (KHC) efficiently and cost-effectively, and;
• Manage the drug formulary, preferred drug list, clinician-administered drug program, and rebate programs to maximize revenue.

Congress established the Texas Medical Assistance Program, or Medicaid, under Title XIX of the Social Security Act of 1965 to pay medical bills for low-income persons who had no other way to pay for care. The program began Sept. 1, 1967, under Title XIX (Medicaid) of the 1965 Amendments to the Social Security Act and SB 2, The Medical Assistance Act of 1967. The Texas Medicaid drug benefit has been an optional service available to all people enrolled in Texas Medicaid since Sept. 1, 1971.

Pharmacy providers enrolled in Medicaid are uniquely positioned to help clients with their pharmacy benefits. Pharmacy providers need to know what pharmacy items Medicaid pays for, which products require prior authorization, and who to contact with questions about claim processing. HHSC provides the resources in this section to assist pharmacy providers in accomplishing this.

Medicaid

Medicaid is a state and federal cooperative program authorized under Title XIX of the Social Security Act and Chapter 32 of the Texas Human Resources Code. It pays for certain medical and health care costs for qualifying people. Pharmacy providers must enroll with HHSC before dispensing outpatient prescriptions to people enrolled in traditional Medicaid or Medicaid managed care. HHSC is responsible for outpatient drugs for people enrolled in traditional Medicaid.

Children's Health Insurance Program

Children in Texas without health insurance and who are not served by, or eligible for, other state-assisted health programs may be able to get low-cost or free health coverage from the Children’s Health Insurance Program (CHIP). Enrollment as a Medicaid pharmacy provider is a prerequisite for pharmacy participation in CHIP.

HHSC manages the CHIP formulary, but MCOs deliver CHIP prescription benefits.

Children with Special Health Care Needs Services Program

The Children with Special Health Care Needs (CSHCN) Services Program provides services and benefits to children 20 and younger with special health care needs and people of any age with cystic fibrosis. It is not a Medicaid program.

Enrollment as a Medicaid pharmacy provider is a prerequisite for pharmacy participation in the CSHCN Services Program.

Kidney Health Care Program

The Kidney Health Care (KHC) Program helps people with end-stage renal disease receive health care services. The program's drug benefit assists with costs for four covered drugs per month and coordinates with Medicare Part D on deductibles, co-insurance amounts, and Part D gap (or "donut hole") expenditures, where the person is responsible for 100 percent of drug costs.

People eligible for Medicaid do not qualify for KHC drug benefits. Benefits available to people enrolled in KHC depend on treatment status, eligibility for benefits from other programs (such as Medicare, Medicaid, or private insurance), and availability of funds.

Enrollment as a Medicaid pharmacy provider is a prerequisite for pharmacy participation in the KHC program.

Healthy Texas Women Program

The Healthy Texas Women (HTW) Program provides access to women’s health and family planning services to eligible women, offering services to low-income women who are 15 through 44 years of age. HHSC only reimburses pharmacy providers for the outpatient prescription products on the HTW formulary.  Family planning drugs and supplies are exempt from the three prescriptions-per-month limits for up to a six-month supply.  The program does not cover emergency birth control.

Enrollment as a Medicaid pharmacy provider is a prerequisite for pharmacy participation in the HTW program.

HHSC is subject to federal and state rules, statutes, and regulations. Refer to citations in the Rules and Statutes Handbook.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA – Public Law 104-191) protects personal health information. People have certain rights concerning their health information, including setting boundaries on how entities use it, establishing proper safeguards, and holding violators accountable. The HIPAA Privacy regulations went into effect on April 14, 2003.

Personal health information may be verbal, written, or electronic communication created, received, or maintained by HHSC. It relates to any person's past, present, or future physical or mental health.

Protected Health Information (PHI) is available to pharmacy providers daily. PHI includes any health care data plus any other identifying information allowing someone to use the data to identify a specific person. Data may include claim information, prior authorizations, medical records, or consent forms.

The pharmacy should never release PHI to anyone who does not need to know the information. If you are asked about a person's PHI and do not feel the person asking needs to know, immediately refer to your supervisor. You should discuss questions or concerns about PHI with your management.