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.