3. Claim Limitations

This section identifies claim limitations for claims processed by Texas HHS (for traditional Medicaid, CSHCN, HTW, and KHC programs) or by the managed care organization.  If no guidance is given for MCO processing, contact the MCO for plan-specific limitations.

3.1 Prescription Limits

3.1.1 Medicaid

People enrolled in Medicaid are limited to three (3) prescriptions per month except for:

  • Children under the age of 21
  • People enrolled in managed care
  • People enrolled in eligibility waiver programs

Drugs and products not counted as part of the three-prescription limit include:

  • Family planning drugs
  • Flu vaccines
  • Opioids for acute pain
  • Diabetic supplies
  • Smoking cessation products
  • Home health supplies
    • Refer to the Home Health Supplies chapter of this manual for more information about these products
  • Mosquito repellents
    • Refer to the Mosquito Repellant chapter of this manual for a list of these products

3.1.1.1 Medicaid  

Payment for up to a six-month supply may be allowed for adults with monthly prescription limitations dependent on the drug prescribed.  Quantities should not exceed a one-month (34-day) supply for people with an unlimited number of prescriptions per month.

3.1.2 CHIP

People enrolled in CHIP have unlimited prescriptions.

3.1.3 CSHCN

People enrolled in the CSHCN Services Program have unlimited prescriptions.  The CSHCN Program is limited by the availability of appropriated funds.  Upon notification to eligible people and providers, services may be adjusted periodically depending upon the current availability of funds. If a person is dually-enrolled in Medicaid and CSHCN, the Medicaid benefit should be used first, including those people limited to 3 prescriptions per month.

3.1.4 KHC 

The KHC program limits people to four (4) prescriptions per month.  The number of prescriptions per month the program pays per person is based on available KHC funds, and the number of prescriptions covered may change depending on budget limitations.  Notification will be sent 30 days in advance if the prescription number limitation changes.

3.2 Refill Limitations

HHSC allows prescription refills based on the DEA drug schedule as outlined in the table below.

DEA Schedule Refill Limitations

No schedule

Original prescription plus 11 refills within 365 days from the written date of the original prescription

Schedule 3, 4, 5 Original prescription plus 5 refills within 185 days from the written date the original prescription

3.3 Refill Authorization

A pharmacy may Refills may only submit refills when requested by the individual. Pharmacy staff must not bill Medicaid unless the person has requested the refill.  This includes pharmacies using automated refill systems.

No partial fill processing is allowed.

3.4 Refill Utilization

A refill is considered too soon, or early, if the person has not used at least 75% of the previous fill of the medication.

3.5.1 Traditional Medicaid & CSHCN

A refill for certain controlled substances, such as tramadol, is considered too soon if the person has not used at least 90% of the previous fill of the medication.  Attention deficit hyperactivity disorder drugs and certain seizure medications are excluded from this requirement.

Refer to the Formulary search, and select the "90% Utilization" filter to identify these drugs.

Claims not meeting the utilization threshold will reject with error code 79.  A previous fill may have been from a different pharmacy.

3.5.2 Refill Too Soon Overrides

3.5.2.1 Vendor Drug Program

Contact the Pharmacy Benefits Access Help Desk to request an override. 

Justifications for an override may include a verifiable dosage increase or anticipated prolonged absences from the state.  Prescribing providers may be asked to verify the reason for the early refill by the pharmacy.

3.5.2.2 Managed care

Contact the MCO for specific requirements and processes related to dispensing early refills.

3.5 Dollar Limits

3.5.1 Vendor Drug Program

Texas HHS limits claims to $9,999.99. Contact the Pharmacy Benefits Access Help Desk for assistance with claims $10,000.00 and greater.