Pharmacy claims are submitted with the number of consecutive days covered by the prescription in the "Days Supply" field (405-D5). Incorrect reporting in this field may impact early refill edits or inaccurate drug use review warnings. Pharmacy providers should divide the quantity by total dosage units per day to identify the correct day supply.

Pharmacy providers must submit a value "1" in the "Dispense as Written (DAW) / Product Selection code" field (408-D8) when a prescribing provider wants a nonpreferred brand name dispensed and hand writes the phrase "Brand Necessary," "Brand Medically Necessary," "Brand Name Necessary," or "Brand Name Medically Necessary" across the face of the prescription.  The value of “1” will reimburse at the normal calculated cost, including comparison to the submitted "Usual and Customary Charge" and "Gross Amount Due" fields.  The value of “1” is not needed if the brand drug prescribed has preferred status on the Texas Medicaid Preferred Drug List.

If an e-prescription is received by a pharmacy with “dispense as written” indicated but without the free text message ("Brand Medically Necessary") or additional note, the pharmacy must contact the prescriber for a new prescription. Submit the claim once the pharmacy receives the e-prescription with both data elements.

Failure of the pharmacy to produce electronic records indicating the proper DAW and “Brand Medically Necessary” in the free-text message for the prescription will result in the claim subject to recoupment. All non-electronic “Brand Medically Prescriptions” (for controlled and non-controlled substances), must continue to comply with current policy and Texas State Board of Pharmacy (TSBP) rules.

Pharmacies submit claims with the following Product/Service ID fields:

• 11-digit National Drug Code (NDC) in the "Product/Service ID" field (407-D7)
• Value "03" in the "Product/Service ID Qualifier” field (436-E1)

The NDC number submitted on the claim transaction must match the NDC number on the package or container dispensed.

The 11-digit NDC number is composed of the following three segments:

• Labeler
  • 5-digit code assigned by the Food and Drug Administration (FDA) and identifies the drug manufacturer
• Product
  • 4-digit code assigned by the drug manufacturer and identifies the specific product
• Package
  • 2-digit code assigned by the manufacturer and identifies the package size

The correct format for pharmacy claim submission is an 11-digit number in a 5-4-2 format. Pharmacy providers must convert any other number, such as a 10-digit number in the 4-4-2, 5-3-2, or 5-4-1 format, before submittal. To correct the NDC place a leading zero in either the labeler code, product code, or package size code to conform to the 5-4-2 format.

Refer to the Multi-ingredient Compounds section for instructions on how to identify the NDC on a multi-ingredient compounds claim.

Pharmacy claims are submitted with billing units in the “Unit of Measure” field (600-28):

• Each (EA), used when the product is dispensed in discreet units
• Gram (GM), used when a product is measured by its weight
• Milliliter (ML), used when a product is measured by its liquid volume

Pharmacy providers should be aware of the correct billing units on certain medications to alleviate billing discrepancies, which can lead to potential audit risks. Quantity for milliliters and grams must be divisible by package size. Some products (such as Risperdal Consta, Humira, Enbrel, Lovenox, Neupogen, Pegasys, and Procrit) may have varying units depending on the NDC number.

Refer to the NCPDP B1 Transaction Payer Sheet for the acceptable unit of measure values on a single ingredient and multi-ingredient compound claim.

Pharmacy providers should dispense the same drug in the same strength no more than once per month, per person. An exception to this is only for medications considered too unstable to be dispensed as a one-month supply. HHSC may refer pharmacy providers not compliant with this policy to the HHSC Office of Inspector General.

Pharmacy providers must submit claims with the amount dispensed at point-of-sale in the "Quantity Dispensed" field (442-E7). The pharmacy must dispense the quantity prescribed or ordered by the prescribing provider except as limited by the policies and procedures described in this manual. When the actual quantity dispensed deviates from the prescribed quantity, the pharmacy must submit for the amount dispensed. Incorrect reporting in this field may prompt drug companies to dispute the claim and cause rebate auditors to review the claim level data.

Drugs such as ear drops, eye drops or ointments, inhalers, and injectable products are packaged in sizes without a whole number. When submitting a claim for a drug packaged in a metric decimal-sized package (e.g. 10.2; 2.5; etc.), the pharmacy should include the decimals on the claim and not round up.

Contact your software vendor for assistance with issues resolving whole number units on the package size and submitting decimal units.