The Medicaid Comprehensive Care Program (CCP) can cover medically necessary drugs and supplies not available through VDP for clients from birth through 20 years. Pharmacies not enrolled with CCP should direct the client to call TMHP to locate a CCP provider. CCP providers submit claims to TMHP for medically necessary drugs, equipment, or supplies not covered by VDP, including over-the-counter drugs, nutritional products, and disposable or expendable medical supplies commonly found in pharmacies.

Pharmacies must complete an application at tmhp.com. Contact the TMHP Contact Center or email TMHP Provider Relations to request assistance from the local TMHP provider relations representative in your area. Refer to the TMHP Contact Center section for contact information.

All CCP services require prior authorization. The Texas Medicaid Provider Procedures Manual (TMPPM) includes prior authorization requirements for services through CCP. Refer to section 2.1.4 of the Children's Services Handbook of the Texas Medicaid Provider Procedures Manual (tmhp.com/resources/provider-manuals/tmppm). Pharmacies submit prior authorizations using CCP Prior Authorization Request Form (TMHP Form F00012).

Refer to the Enrollment Forms for this and other enrollment forms.

Durable medical equipment (DME) is equipment or appliances manufactured to withstand repeated use; ordered by a physician for use in a client’s home; and required to correct or ameliorate a client's disability, condition, or illness. DME includes vitamin and mineral products. DME is not typically available as a pharmacy benefit.

Certain supplies and select vitamin and mineral products are a covered pharmacy benefit of the following programs:

• Medicaid
• CHIP
• CSHCN Services Program
• KHC Program

A pharmacy must enroll as a DME provider to provide the full array of durable medical equipment and supplies. Pharmacies must complete an application at tmhp.com. Contact the TMHP Contact Center or e-mail TMHP Provider Relations to request assistance from the local TMHP provider relations representative in your area. Contact the TMHP Contact Center for assistance.

All claims for DME items require a completed Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form (TMHP Form F00030). Refer to the Enrollment Forms for this form.

Pharmacy providers must complete the Direct Deposit Authorization to receive weekly payments through direct deposit or to change bank information, such as your financial institution or account number or cancel your account. An account change will result in the pharmacy provider receiving paper warrants until HHSC Accounts Payable completes the authorization process.

Submit the form through PEMS for processing. Contact TMHP Provider Enrollment page for further instructions.

Federal law requires all pharmacy providers receiving or making annual Medicaid payments of $5 million or more to educate their employees, contractors, and agents about fraud and false claims laws and the whistleblower protections available under those laws.

Medicaid-enrolled pharmacy providers must have a current license to remain active in Medicaid and other state healthcare programs. Pharmacy providers must keep their license information current to continue participation by submitting license changes and renewals through a PEMS maintenance request.

Enrolled pharmacy providers must notify HHSC through PEMS of any change to the information provided in their application Per the pharmacy enrollment agreement (Part 3, Subpart F). This includes the following information:

• Pharmacy type
• Billing and physical addresses
• Phone and fax numbers
• Key personnel (i.e., owners, control interests, pharmacists)
• Financial information, including direct deposit
• Store closure

Refer to your pharmacy enrollment agreement for all requirements of enrollment information updating processes.

In a change of ownership or control, an owner must notify HHSC through PEMS at least 15 business days before the change of ownership or control occurs. HHSC does not perform retroactive changes of ownership regarding the pharmacy enrollment agreement.

Pharmacies can verify their information on the Pharmacy search (txvendordrug.com/providers/pharmacy-search) and should submit corrections through PEMS. If your information is incorrect or incomplete, you risk not receiving correspondence from HHSC or TMHP. Failure to update enrollment information could result in HHSC placing claims on vendor hold or the termination of your enrollment per the pharmacy enrollment agreement.

Some pharmacies offer discount price clubs and other membership discount card programs. These programs typically have offered discount drug prices to all customers and given the discounted drug prices to the cash-paying customers who enrolled in the program and paid a nominal membership fee. The Usual and Customary (UAC) Price regulation does not exclude persons who pay a nominal membership fee from the general public. Therefore, pharmacy discount membership program prices constitute discounts given or advertised to the general public pursuant to TAC Section 355.8544 (Subchapter J: Usual and Customary Prices), as well as applicable federal law. See, e.g., U.S. ex rel. Garbe v. Kmart Corp., 824 F.3d 632 (7th Cir. 2016). Pharmacy discount membership program prices must be submitted as the UAC price (as previously indicated in the April 2008 edition of the RxUpdate newsletter formerly published by VDP, refer to the April 2008 newsletter (PDF)), unless the price would be greater than the most frequently charged price for the same drug.

Refer to the Usual and Customary section for the definition of the UAC price.

The pharmacy must retain all records and documents referenced in the pharmacy enrollment agreement (Part 3, Subpart I) for five years from the service date. The pharmacy must also maintain for five years all records required by federal and state laws relating to counseling and patient medication records, including TAC Section 291.33(c) (Operational Standards) and 291.34(c)(3) (Records).

If any litigation, audit, review, or dispute resolution begins at a time when the pharmacy provider would have otherwise been authorized to destroy the records (e.g., five years and a day after the date of service) and the pharmacy provider still has the records, the pharmacy provider must maintain those records until the reviewer concludes the process. For record retention, the reviewer concludes the process only after HHSC provides written notification, permanently resolving the issue.

Enrolled pharmacy providers must revalidate every five years or stated otherwise in the Provider Agreement. As part of revalidation, TMHP conducts a full screening appropriate to the providers' risk category according to the CMS Medicaid Provider Enrollment Compendium. CMS designates pharmacies as limited risk providers. The screening will include licensure and background checks using various federal and state databases to verify whether providers meet Medicaid enrollment criteria. TMHP will disenroll pharmacy providers not revalidating their enrollment by the designated date.

The pharmacy's software vendor must support the current National Council for Prescription Drug Program (NCPDP) telecommunication standard, including the "Additional Message Information" field (526-FQ) in the B1 response.

HHSC will terminate enrollment for pharmacies without any claim payment within a continuous twelve-month period. If HHSC terminates your enrollment for inactivity, you must reapply by submitting a new application through PEMS.

Some pharmacies honor discount prices advertised to cash-paying customers by third-parties. Pharmacies may or may not contract with third-parties to adjudicate and administer these discounts.

Only people whose prescriptions are paid by third party payers, such as health insurers, governmental entities and Texas Medicaid, are excluded from the general public. Refer to TAC Section 355.8544 (Subchapter J: Usual and Customary Prices).

The involvement of a third-party in offering, advertising, adjudicating, or administering the discount price a person pays does not remove the person from the general public, and the third-party discount price must be included in the UAC price determination if honored by the pharmacy.

As with pharmacy discount membership programs, the requirement a person pay a nominal fee to enroll in the third-party’s discount program does not remove the person from the general public or otherwise exempt the discount price from the UAC price determination. Some third-party discount plan prices are only offered to segments of the general public, such as discount plans for senior adults, employees/retirees of companies, etc. These discount prices must be included in the UAC price determination if the person would have qualified as a member of the same group or segment of the public, but-for the person’s status as a Texas Medicaid beneficiary.

Refer to the Usual and Customary section for the definition of the UAC price.