8.7. Drug-specific Requirements

This section identifies certain drug requirements for claims processed by HHSC (for traditional Medicaid, CSHCN, HTW, and KHC programs) or by MCOs. If no guidance is given for MCO processing, then the pharmacy staff should contact the MCO for claim submission requirements.

8.7.1 Anorexic Products

8.7.1.1. HHSC

Traditional Medicaid

HHSC requires prior approval for ages 21 years and over, and will deny weight management diagnoses. Claims will reject with NCPDP error code 75 and include the message “Prior Authorization not on file. Contact Pharmacy Benefits Access” in the “Additional Message Information” field (526-FQ). VDP clinician staff determine coverage, and no form is required.

8.7.2. Anti-Fungal Products

8.7.2.1. HHSC

Traditional Medicaid

HHSC limits people to a 180-day supply per calendar year and will reject claims with error code “76” and the message “Days Supply Limited per Year by Program. Contact Pharmacy Benefits Access” in the “Additional Message Information” field (526-FQ). VDP clinician staff determine coverage, and no form is required.

8.7.3. Biosynthetic Growth Hormone Products

8.7.3.1. HHSC

Traditional Medicaid

Prior approval and documentation of appropriate diagnoses are required. Prior authorization criteria are available online. Refer to the "Pharmacy Prior Authorization" section of the Contact Information chapter of this manual to contact the Texas Prior Authorization Call Center.

CSHCN Services Program

HHSC requires prescribing providers to submit prior authorization documentation of appropriate diagnoses. The prescribing provider must complete one of the following sets of forms:

  • Growth Hormone Products Authorization Request (HHS Form 1312)
  • Texas Standard Prior Authorization Form for Prescription Drug Benefits (Texas Department of Insurance Form TDI NOFR002) and Growth Hormone Agents - Addendum (HHS 1327)

8.7.4. Blood Factor Products

8.7.4.1. HHSC

Traditional Medicaid

Pharmacy staff must submit one compound claim when the drugs are of the same active ingredient, from the same drug manufacturer, and are the same drug formulation, intended for use together with each dose. The multi-ingredient compound claim should contain one line-item per NDC. Refer to the System Requirements chapter of this manual for claim submission requirements for multi-ingredient compounds.

CSHCN Services Program

Products are covered and used in the treatment of hemophilia. Claims are processed and paid by TMHP.

8.7.5. Compound-only

8.7.5.1. HHSC

Some drugs are only payable when submitted as part of a multi-ingredient compound claim.  After searching for a drug using the formulary search, refer to the drug details page and locate the "Compound-only Use by Program" segment.

Not all drugs in a multi-ingredient compound claim are payable. Refer to the System Requirements chapter of this manual for instruction on how to receive payment for non-covered products part of a multi-ingredient compound claim.

8.7.6. Cough and Cold Products 

Cough and cold combination products for children less than 2 years of age are not covered. This excludes single entity antihistamines.  Other uses of cough and cold products for children less than 6 years of age are subject to clinical prior authorization.  Products containing acetaminophen, ibuprofen, or narcotics for children less than 6 years of age are not covered.

Products require prior authorization if the product is not indicated for the person’s age.  Products containing a narcotic will require prior authorization if a child is between 6 and 12 years of age.

8.7.7. Cystic Fibrosis Treatment Products

8.7.7.1. HHSC

CSHCN Services Program

HHSC requires prior authorization for claims for Cayston, Kalydeco, Pulmozyme, and inhaled tobramycin. Prescribing providers complete and submit the Cystic Fibrosis Treatment Products Authorization Request (HHS Form 1143).

Pharmacy staff can perform an E1 eligibility verification transaction to find a person’s most current period of approval for Tobramycin.

  • Refer to the System Requirements chapter of this manual for information about claim transactions.
  • Refer to the "Field Responses for an Accepted Eligibility Verification" in the NCPDP E1 Transaction Payer Sheet for further explanation about the response.

8.7.8. Enzyme Replacement Therapy Products

8.7.8.1. HHSC

CSHCN Services Program

HHSC will reject claims with NCPDP error code “75” and the message “Prior Authorization not on file.  Contact Pharmacy Benefits Access” in the “Additional Message Information” field (526-FQ).

8.7.9. Erectile Dysfunction Products

Erectile dysfunction drugs are not a covered benefit of any program.

8.7.10. Family Planning Products

8.7.10.1. HHSC

Traditional Medicaid

Certain family planning drugs are covered and do not count towards a person’s three prescription-per-month limitation. Refer to the formulary search and select the "Family Planning" filter to identify these drugs.  

CSHCN Services Program

The prescribing physician must compose a letter of medical necessity (LMN) on office stationery.  Pharmacy staff must submit the LMN by fax to the CSHCN Service Program.

8.7.10.2. Managed Care

CHIP

CHIP covers birth control for certain diagnoses. Contraceptives are only covered for non-contraceptive medical purposes. Contact the MCO for claim submission requirements. 

8.7.12. Human Immunodeficiency Virus Products

8.7.12.1. HHSC

CSHCN Services Program

CSHCN allows 60 days of drug coverage with prior authorization.  The 60-day timeframe provides coverage while the person enrolls and receives approval or denial from the Texas HIV Medications Program.

Contact CSHCN to receive prior authorization. 

Contact the Texas HIV Medication Program at 1-800-255-1090 or online at dshs.texas.gov/hivstd/meds/. If the person is not eligible for the HIV program, the medications may be an ongoing benefit through the CSHCN Services Program if the person remains eligible.

8.7.13. Insulin and Insulin Syringes

8.7.13.1. HHSC

Traditional Medicaid

Insulin syringes are a benefit only when the syringes are for insulin use.  Insulin syringes prescribed for other injectable drugs should be billed as a Medical benefit through TMHP.  Only the insulin counts toward the person’s prescription-per-month limit.  The pharmacy may submit claims for insulin with a day supply based on stability rather than the actual dose.

KHC Program

Prescriptions for syringes and home health supplies count toward the KHC four prescription-per-month limit.

8.7.14. Influenza Vaccine

8.7.14.1. HHSC

Traditional Medicaid

During influenza season, pharmacies may bill for influenza vaccines provided to people aged seven and older in a pharmacy setting for influenza vaccines available on the Medicaid formulary as part of the pharmacy benefit.   The pharmacist administering the vaccine does not have to enroll with TMHP but must follow the TSBP rules related to certification to immunize and vaccinate.

  • Refer to 22 TAC Section 295.15 (Administration of Immunizations or Vaccinations by a Pharmacist under Written Protocol of Physician) 

Administering pharmacists are health care professionals licensed by the TSBP to practice as a pharmacist, have met and maintained the eligibility requirements outlined in law, and have been certified by the TSBP to administer vaccines. 

Administering pharmacists are under the supervision of a physician under state law and may administer immunizations or vaccinations only under a physician’s written protocol authorizing the administration. Pharmacists are employed and remunerated by a pharmacy for their services.  If the program’s services are covered and reimbursable, payment may be made to the pharmacy employing the licensed pharmacist. HHSC will reimburse pharmacies for the ingredient costs and applicable administration fees.

Refer to the Formulary search to identify these products.

8.7.14.2. Managed care

During influenza season MCOs are required to allow pharmacies to bill for influenza vaccines provided to people aged seven and older in a pharmacy setting. MCOs must cover all influenza vaccines available on the Medicaid and CHIP formularies as part of the pharmacy benefit. 

MCOs must reimburse pharmacies for the ingredient cost and applicable administration fees for flu vaccines. 

Refer to the Pharmacy MCO Assistance Chart for the pharmacy call center phone numbers for each MCO.

8.7.15. Kidney Transplant Drugs

8.7.15.1. HHSC

KHC Program

Kidney transplant drugs require prior authorization. Claims reject with error code “75” and the message “Call KHC Program (800) 222-3986” in the “Additional Message Information” field (526-FQ).

8.7.16. Long-Acting Injectables

8.7.16.1. HHSC

Traditional Medicaid

Pharmacists may administer long-acting injectables (LAIs) in a pharmacy setting for people in Medicaid with a valid prescription. Individual pharmacists can administer medications under a physician's delegation as authorized by state law. 

  • Refer to Section 554.004 (Administration of Medication,  Pharmacy Practice Act.) of the Texas Occupation Code. 

The pharmacy, not the individual pharmacist, submits claims for these services using the standard pharmacy claim transaction and is reimbursed for an ingredient cost, dispensing fee, and administration fee for each LAI claim processed.

Refer to the VDP website "Pharmacy Payer Sheets" page to review specific transaction, segment, and field requirements.

Administering pharmacists are health care professionals licensed by the TSBP to practice as a pharmacist, have met and maintained the eligibility requirements outlined in the law, and are under the supervision of a physician. Pharmacists are employed and remunerated by a pharmacy for their services. If the program's services are covered and reimbursable, payment may be made to the pharmacy employing the licensed pharmacist.

Refer to the Formulary search to identify drugs eligible for administration in a pharmacy.

8.7.16.2. Managed care

The pharmacy benefit allows pharmacists to administer long-acting injectable antipsychotics and opioid antagonists to treat a substance use disorder or opioid use disorder.

MCOs must reimburse pharmacies for the ingredient cost, dispensing fee, and applicable administration fees for certain long-acting anti-psychotics, opiate dependence treatments, and emergency treatment for known or suspected opioid overdoses.

Refer to the Pharmacy MCO Assistance Chart (PDF) for the pharmacy call center phone numbers for each MCO.

Refer to the Formulary search to identify drugs eligible for administration in a pharmacy.

8.7.17. Long-Acting Reversible Contraception Products

Providers can prescribe and obtain long-acting reversible contraception (LARC) products are on the Medicaid and HTW formularies from certain specialty pharmacies for women enrolled in Medicaid (traditional and managed care) or the HTW Program.

Refer to the Product search and select the "LARC" filter to identify products available through the pharmacy benefit.

LARC products are only available through certain specialty pharmacies working with LARC manufacturers.  Providers who prescribe and obtain LARC products through the specialty pharmacies listed will be able to return unused and unopened LARC products to the manufacturer's third-party processor.

Prescribing providers may continue to obtain LARC products through the existing buy-and-bill process.

8.7.18. Opioids

8.7.18.1. Limitations

For many people, substance use disorder starts after initially receiving opioid prescriptions for an episode of acute pain. To encourage the appropriate use of opioids and reduce the over-prescribing of opioids, Texas Medicaid has implemented the requirements in this section. The requirements in this section do not apply to clients who are: 

  • Receiving hospice care or palliative care
  • Being treated for cancer
  • Residing in a long-term care facility
  • Residing in a facility in which residents receive opioid substitution therapy for the treatment of opioid use disorder (OUD). 

The requirements also do not apply to other clients that HHSC elects to exempt based on an objective, confirmable physical pathology known to cause severe chronic pain that is not ameliorated by other therapies and for which opioid treatment is appropriate (e.g., sickle cell disease). If diagnoses are not available in the medical data, prescribers can request exemptions on a case-by-case basis through the pharmacy prior authorization process.

8.7.18.2. Prospective Safety Edits

The Medicaid policies and processes listed below are conducted automatically during the pharmacy claims submission process.

8.7.18.2.1. Morphine Milligram Equivalents

Morphine milligram equivalents (MME) per day is used to compare the potency of one opioid to another. The clinical decision for the MME per day recommendations varies depending on the person's opioid use. Additionally, the Centers for Disease Control and Prevention (CDC) recommends starting opioid treatment with an immediate-release/short-acting formulation at the lowest effective dose instead of an extended-release/long-acting formulation.

A person is considered "opioid-naïve" if the client has taken opioids for a duration that is less than or equal to seven days in the last 60 days. For clients who are opioid- naïve, providers must submit a one-time prior authorization request for:

  • An opioid prescription that exceeds a ten-day supply.
  • A prescription for a long-acting opioid formulation.
  • A claim or combination of claims in which the total daily dose of opioids exceeds 90

The one-time requirement for prior authorization does not apply to subsequent claims because the member will no longer be “opioid-naïve.” The duration of the prior authorization is equal to the days’ supply of the claim.

For clients who are not opioid naïve, prior authorization is required for opioid prescriptions if the total daily dose of opioids exceeds 90 MME. For those patients who may require a tapering plan, providers would determine the development and management of a person-specific course of therapy to help manage withdrawal symptoms.  A prescriber may request a tapering plan through the pharmacy prior authorization process on a case-by-case basis. Prior authorization approvals last for six-months.

8.7.18.2.2. Days’ Supply Limits

Opioid prescriptions for the treatment of acute pain are rarely required for more than ten days. To reduce the risk of addiction and the diversion of unused opioids, opioid prescriptions for clients who are opioid naïve are limited to a maximum ten-day supply without prior authorization.

8.7.18.2.3. Fee-For-Service Three Prescription Limit

Prescriptions for opioids to treat acute pain for clients who are 21 years of age and older are exempt from the three-prescription-per-month limit for members in fee-for-service.

8.7.18.2.4. Prospective Drug Utilization Review Alerts

Medicaid returns prospective drug utilization review alerts for pharmacists on all claims when:

  • opioids and benzodiazepines are used concurrently; and
  • opioids and antipsychotics are used concurrently;

Refer to the "Prospective Drug Utilization Review" section of the Drug Utilization Review chapter of this manual for more information about alerts. 

8.7.19. Makena

8.7.19.1. HHSC

Traditional Medicaid

Makena (hydroxyprogesterone caproate injection) requires a clinical prior authorization. Prescribing providers complete the Makena Clinical Prior Authorization Request (HHS Form 1345) and submit for review.

8.7.19.2. Managed care

Clinical prior authorization may be required.  Providers and pharmacy staff should contact MCO for requirements and forms.  Refer to the "Managed Care" section of the Contact Information chapter of this manual for form submission requirements. 

8.7.20. Migraine Medications

8.7.20.1. HHSC

Traditional Medicaid

HHSC limits medications to specific quantities per calendar month for each drug. Claims exceeding this limitation will reject with error code “76” and the message “Exceeds Max Product Quantity/Month – MI” in the “Additional Message Information” field (526-FQ).

8.7.21. Over-the-counter Drugs

8.7.21.1. HHSC

Medicaid, CSHCN, and KHC cover some over-the-counter (OTC) drugs, except for clients residing in a nursing facility.

8.7.21.2. Managed care

CHIP

Insulin, diabetic supplies, and mosquito repellant are the only covered OTC items.

8.7.22. Peritoneal Treatment Products

8.7.22.1. HHSC

KHC

HHSC will reject peritoneal product claims with NCPDP error code “75” and the message “Prior Authorization not on file, call the Pharmacy Benefit Access” in the “Additional Message Information” field (526-FQ).

8.7.23. Premium Preferred Generic Drugs

6.22.1 HHSC

HHSC reimburses pharmacies an additional $0.50 incentive fee for dispensing premium preferred generic (PPG) drugs on Medicaid claims.

The PPG amount appears in the "Incentive Amount Paid" field (521-FL) of the paid claim response.  The incentive does not apply to $0.00 total payment amount claims.  Refer to the Drug Pricing and Reimbursement chapter of this manual to learn more about state reimbursement calculation.

8.7.24. Pediculosis Treatment Products

6.23.1 Vendor Drug Program

Prescribing providers can write one prescription per person in an amount covering an entire family if a person is diagnosed with lice or scabies.

8.7.25. Prenatal Vitamins

6.24.1 Vendor Drug Program 

HHSC limits vitamins to females under the age of 50, and will reject claims for improper age or gender:

  • Error code 6Ø ("Product Not Covered for Patient Age – PN")
  • Error code 61 ("Product Not Covered for Patient Gender – PN")

8.7.26. Pulmonary Hypertension Drugs

8.7.26.1. HHSC

CSHCN Services Program

The prescribing physician must compose a letter of medical necessity (LMN) on office stationery. Pharmacy staff must submit the LMN by fax to the CSHCN Service Program.

8.7.27. Specialty Drugs

8.7.27.1. HHSC

Traditional Medicaid

Specialty drugs on the SDL are available as either an outpatient pharmacy benefit, a medical/physician benefit, or both.

Refer to the Texas Medicaid Provider Procedure Manual for brand/generic availability, diagnosis restrictions, and billing information of products covered as a medical/physician benefit. Refer to the “Texas Medicaid and Healthcare Partnership” section of the Contact Information chapter of this manual for form submission requirements.

8.7.27.2. Managed care

HHSC provides a quarterly specialty drug list (SDL) to MCOs identifying specialty drugs offered exclusively through the MCO's specialty pharmacy network.

8.7.28. Stadol

8.7.28.1. HHSC

KHC

Stadol is limited to 10 milliliters (or 4 bottles) per calendar month. HHSC will reject claims exceeding this limitation with NCPDP error code “76” (“Plan Limitations Exceeded”) and the message “Exceeds Max Product Quantity/Month – ST” in the “Additional Message Information” field (526-FQ).

8.7.29. Synagis

Synagis is used to help prevent severe lung disease caused by a respiratory syncytial virus (RSV) in infants born prematurely and other children at high risk for severe lung disease from RSV.

HHSC bases RSV season dates on the county of residence. RSV appears earlier in some counties and remains active later in other counties. HHSC uses RSV statistics from prior years plus regular virology reports to determine the season's dates for each region and reserves the right to extend or end a season after subsequent review of RSV levels in each region. MCO medical directors can end the RSV season for their MCO by service area if they demonstrate the local virology has dropped below 10% positivity for two consecutive weeks.

Refer to the Synagis page on the VDP website to learn more about seasonal requirements and schedules.

8.7.29.1. Managed care

Medicaid and CHIP require the Texas Standard Prior Authorization Form for Prescription Drug Benefits (Texas Department of Insurance Form NORFR002).  Prescribing providers and pharmacy staff should contact the MCO for prior authorization requirements and forms. MCOs may require additional information in addition to the MCO-specific addendum form. The MCO’s form will reflect the appropriate MCO contact information and reconsideration request process.

Refer to the “Managed Care” section of the Contact Information chapter of this manual for contact instruction.

8.7.29.2. Traditional Medicaid

Prior authorization is a two-step process. The prescribing provider completes the Standard Prior Authorization Request and Synagis Standard Prior Authorization Addendum (HHSC Form 1321) and submits the prescription for Synagis and any supporting information to the Medicaid-enrolled pharmacy. Refer to the form for requirements and submission instructions. Failure to submit both forms will result in authorization denial. Pharmacy staff then submit the form to the Texas Prior Authorization Call Center. Refer to the "Pharmacy Prior Authorization" section of the Contact Information chapter of this manual for submission requirements.

8.7.29.3. CSHCN Services Program

Prior authorization is a two-step process. The prescribing provider completes the Standard Prior Authorization Request and Synagis Standard Prior Authorization Addendum (HHSC Form 1325) and submits the prescription for Synagis and any supporting information to the CSHCN-enrolled pharmacy. Refer to the form for requirements and submission instructions. Failure to submit both forms will result in authorization denial. Pharmacy staff submit the form to the CSHCN Services Program. Refer to the "Pharmacy Prior Authorization" section of the Contact Information chapter of this manual for form submission requirements.

8.7.30. Tramadol with Codeine

8.7.30.1. HHSC

Traditional Medicaid

Products containing tramadol and codeine are not available for children younger than 12. HHSC will deny Medicaid claims, including multi-ingredient compound claims, with NCPDP error code “60” (“Product/Service Not Covered For Patient Age”) and include the message “Not Covered For Under Years Of Age” in the “Additional Message Information” field (526-FQ).

8.7.31. Xenical

8.7.31.1. HHSC

Traditional Medicaid

Xenical is available only to treat hyperlipidemia and is not approved for concurrent use with other cholesterol-lowering agents. HHSC clinician staff will determine coverage. Prescribing providers complete the Medicaid Xenical Authorization Request (HHS Form 1331) and submit for review