Claim Limitations
This section identifies claim limitations for claims processed by HHSC (for traditional Medicaid, CSHCN, HTW, and KHC programs) or by the managed care organization. Pharmacy providers should contact the client's specific MCO for details.
Dollar Limits
HHSC
HHSC limits claims to $9,999.99. Contact the Pharmacy Benefits Access Help Desk for assistance with claims $10,000.00 and greater.
Prescription Limits
Medicaid
People enrolled in Medicaid are limited to three prescriptions per month except for:
- Children under 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 the following:
- COVID-19 oral antivirals
- COVID-19 test kits
- COVID-19 vaccines
- Diabetic supplies
- Family planning products
- Home health supplies
- Mosquito repellents
- Influenza vaccines
- Opioids for acute pain
- Smoking cessation products
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.
CHIP
People enrolled in CHIP have unlimited prescriptions, with a few exclusions, including the following:
- Contraceptive medications prescribed only for the purpose of primary and preventative reproductive health. Refer to the Family Planning Products section for more information.
- Medications for weight loss or gain
CSHCN
People enrolled in the CSHCN Services Program have unlimited prescriptions. The availability of appropriated funds limits the CSHCN Program. Upon notification to eligible people and providers, services may be adjusted periodically depending on the current availability of funds. If a person is dually enrolled in Medicaid and CSHCN, the Medicaid benefit should be used first, including those limited to 3 monthly prescriptions.
KHC
The KHC program limits people to four 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. KHC will send a notification 30 days in advance if the prescription number limitation changes.
The federal Comprehensive Immunosuppressive Drug Coverage for Kidney Transplant Patients Act of 2020 became effective Jan. 1, 2023. The Act extends lifetime Medicare coverage of immunosuppressant drugs for Medicare-eligible kidney transplant recipients indefinitely. This Act only provides coverage of immunosuppressant drugs and does not provide full healthcare coverage. Refer to the Medicare End Stage Renal Disease website for more information.
Refill Authorization
Pharmacy providers should only submit refills when requested by the client, and must not bill Medicaid unless the client has requested the refill. This includes pharmacies using automated refill systems. No partial fill processing is allowed.
Refill Limitations
HHSC allows prescription refills based on the United States Drug Enforcement Administration (DEA) drug schedule as outlined 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 |
Refill Too Soon Overrides
HHSC
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.
Managed care
Contact the MCO for specific requirements and processes related to dispensing early refills.
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.
Traditional Medicaid and 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 NCPDP error code "79". A previous fill may have been from a different pharmacy.