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

HHSC

HHSC limits clients enrolled in traditional Medicaid to a 180-day supply per calendar year. The claims system 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). HHSC clinician staff determine coverage, and no form is required.

Traditional Medicaid

HHSC requires prior approval with documentation of an appropriate diagnosis. Refer to the Growth Hormone clinical prior authorization criteria document for more information.

CSHCN Services Program

HHSC requires prior authorization for specific diagnoses involving growth hormone deficiency. If an initial or extension request cannot be approved, the request may be sent to program staff for medical review and reconsideration. Prescribing providers complete and submit the Biosynthetic Growth Hormone Products Prior Authorization Request (CSHCN) (HHS Form 1327).

Prescribing providers send the completed form to the CSHCN-enrolled pharmacy, which submits the form. A program-approved provider must complete and sign this form annually, certifying that the client requires these medications.

Traditional Medicaid

Pharmacy providers 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 with each dose. The multi-ingredient compound claim should contain one line item per NDC. Refer to the multi-ingredient compounds section for claim submission requirements.

CSHCN Services Program

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

In Dec. 2021, the Food and Drug Administration (FDA) began issuing Emergency Use Authorizations (EUA) for oral COVID-19 antiviral therapies. ;HHSC allows Molnupiravir and Paxolvid at no cost to clients enrolled in Medicaid, CHIP, and the CSHCN Services Program.

COVID-19 oral antivirals must be approved or have a EUA by the FDA, and healthcare providers must order per criteria specified by the FDA approval or authorization.

The EUA requires Paxlovid and Molnupiravir oral antivirals to be accessed by prescription only. HHSC does not require prior authorization for these medications and is not authorized by the FDA to prevent COVID-19.

Paxlovid treats mild-to-moderate COVID-19 in adults and children 12 years and older at high risk for progression to severe COVID-19. Healthcare providers should initiate Paxlovid after diagnosis of COVID-19 within five days of symptom onset.

Molnupiravir treats mild-to-moderate COVID-19 in adults 18 years and older. The medication is indicated to treat individuals with a confirmed diagnosis of COVID-19 who are at high risk for progression-to-severe COVID-19 and for whom alternative treatment options authorized by the FDA are not accessible or clinically appropriate. Healthcare providers should initiate Molnupiravir after diagnosis of COVID-19 and within five days of symptom onset.

Refer to the Texas Department of State Health Services Information for Hospitals and Healthcare Professionals for more information about Paxlovid and Molnupiravir.

The medication has no ingredient cost because the federal government has purchased treatment courses. DSHS will distribute the medicines to pharmacies. Pharmacies should submit a dispensing fee of no less than $8.08 at a minimum because of no ingredient cost.

HHSC allows COVID-19 at-home test kits at no cost to people enrolled in Medicaid, CHIP, CSHCN, HTW, and KHC. HHSC allowed the benefit for clients in fee-for-service Medicaid, CSHCN, HTW, and KHC as of Jan. 3, 2022, and since Jan. 17, 2022, for clients enrolled in managed care.

Clients may obtain COVID-19 at-home test kits from a Medicaid-enrolled retail pharmacy with or without a prescription from a prescribing provider. An adjudicated pharmacy claim is required for reimbursement of a COVID-19 at-home test.

A list of products is available through the Formulary search (txvendordrug.com/formulary/formulary-search). Users can search by product name, the 11-digit NDC, or click the "COVID-19 vaccine" checkbox to review details about each test kit. HHSC selected these products based on their status under the Emergency Use Authorization (EUA) from the U.S. Food and Drug Administration.

Clients may obtain a maximum quantity of 4 tests per calendar month. Pharmacies can process prescriptions using single packs (1 test) or multi-pack test kits (2 tests), equaling a total of 4 at-home COVID-19 tests per month. For example:

• 1 single pack kit (1 test) allows 4 kits per calendar month
• 1 multi-pack kit (2 tests) allows 2 kits per calendar month

Quantities dispensed can be up to the maximum allowed of 4 tests per calendar month with or without a prescription. Pharmacies must submit a separate claim for each transaction of a COVID-19 test kit.

Without a Prescription

Pharmacies must use the information below for pharmacy claims without a prescription. Refer to the Claims Billing (B1) Transaction payer sheets for specific transaction, segment, and field requirements.

• NPI: 3070440003 in the "Prescriber ID" field (411-DB)
• Provider last name: Test Kit Prescriber
• Provider first name: COVID
• Address: HHSC
• License: CTK001

Refills are not authorized when there is no prescription.

With a Prescription

When processing a prescription from a prescriber for a COVID-19 test kit, the prescribed quantity and applicable refills may not exceed the maximum benefit limit of 4 tests per calendar month.

In FFS Medicaid, HTW, KHC, and CSHCN, pharmacy claims exceeding the maximum quantity of 4 tests per calendar month will reject with NCPDP reject code "76" (Plan limitation exceeded) and the message "Only 4 COVID-19 tests allowed per calendar month" in the "Additional Message Information" field (526-FQ).

COVID-19 at-home test kits will have a reimbursement rate maximum price with no dispensing, delivery, or incentive fees and will not count against an FFS client's 3-prescription-per-calendar-month limit.

On Jan. 31, 2020, the Secretary of Health and Human Services declared the 2019 novel coronavirus (COVID-19) was a public-health emergency for the United States as of Jan. 27, 2020. In Dec. 2020, the Food and Drug Administration (FDA) began issuing Emergency Use Authorizations for COVID-19 vaccines. A list of COVID-19 products is available through the Formulary search (txvendordrug.com/formulary/formulary-search). Users can search by product name, the 11-digit NDC, or click the "COVID-19 vaccine" checkbox to review details about each vaccine.

Immunization Program Portal

The federal government distributes the COVID-19 vaccines. Pharmacies, retail clinics, providers, and other care sites receiving and administering the COVID-19 vaccine must complete the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Program Provider Agreement.

Providers should contact the Texas Department of State Health Services (DSHS) Immunization Program to register through the Texas DSHS Immunization Portal.

Claim Processing

HHSC set the fee-for-service (FFS) reimbursement rate to align with Medicare. For vaccines requiring a single or two doses, the FFS initial dose's administration reimbursement rate is $40.00. HHSC bases reimbursement on the submitted value in the "Incentive Amount Submitted" field (438-E3). The claim will pay $0 if the field is blank.

The Public Readiness and Emergency Preparedness Act allows certain providers to order and administer the COVID-19 vaccine, including pharmacists and pharmacy interns. To process a pharmacy vaccine administration claim, pharmacy staff should submit the following:

Pharmacies will receive a rejection for FFS claims when submitting a second dose claim if a client received their first dose from a non-Medicaid pharmacy. If your second dose claim is correct, the pharmacy can submit the following information to bypass the rejection:

HHSC

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

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

HHSC provides coverage for certain cough and cold products for Medicaid clients. Covered products in this category include analgesics, antihistamines, antitussives, decongestants, and expectorants.

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

Traditional Medicaid

HHSC requires prior authorization for claims for Kalydeco, Orkami, Symdeko, and Trikafta. Prescribing providers complete and submit the Cystic Fibrosis Treatment Agents Prior Authorization Request (Medicaid) (HHS Form 1338).

CSHCN Services Program

HHSC requires prior authorization for the following specific cystic fibrosis treatment agents:

• HHSC covers Kalydeco and Pulmozyme for treating cystic fibrosis as prescribed by a program-approved pulmonologist and may approve treatment for six months with subsequent approval for one year.  Pharmacy providers can only dispense one month’s supply at a time.
• HHSC covers Cayston and inhaled Tobramycin for treating cystic fibrosis as prescribed by a program-approved pulmonologist and limits an administration cycle of 28 days of treatment followed by 28 days with no agent treatment.
  • Pharmacy providers can submit an eligibility verification transaction to find a client's most current period of approval for Tobramycin. Refer to the Eligibility Verification (E1) Transaction for specific transaction, segment, field requirements, and response messages.

Prescribing providers complete and submit the Cystic Fibrosis Treatment Products Authorization Request (HHS Form 1143). The provider must submit the form annually, certifying the client requires these medications. Providers must supply medical necessity documentation for clients with a diagnosis other than cystic fibrosis.

Traditional Medicaid

There is no preferred brand of diabetic test strip for Medicaid. Prescribers may choose any test strip on the Medicaid formulary.

Medicaid Managed Care

Some MCOs have a preferred brand of glucose monitoring test strips. If no brand is listed, the prescriber may choose any brand on the Medicaid Formulary. Note that MCOs must cover all test strips even if they are non-preferred.

Traditional Medicaid

HHSC requires prior authorization for Emflaza (deflazacort). Deflazacort is FDA-approved for the treatment of Duchenne muscular dystrophy (DMD) in clients 2 years and older. Prescribing providers complete and submit the Emflaza Standard Prior Authorization Addendum (HHS Form 1347).

Treatment approval criteria for Emflaza include the following:

• Clients 2 years and older with a diagnosis DMD.
• The client has tried prednisone for three months or longer and has one the following adverse events as a result prednisone use:
  • Cushingoid appearance;
  • Central (truncal) obesity;
  • Undesirable weight gain (greater than or equal to 10% body weight gain over a six-month period);
  • Diabetes and/or hypertension that is difficult to manage; or
  • Experienced a severe behavioral adverse event.

For renewal requests, prescribing providers should complete sections 1, 5 and 6 of the form.

Reasons for denial include but are not limited to the following:

• Less than 2 years old
• Use of CYP3A4 in last 90 days
• No previous trial with prednisone

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).

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

Traditional Medicaid

Certain family planning drugs do not count towards a client's three prescription-per-month limitation. Refer to the Formulary search and select the "Family Planning" filter to identify these drugs, which include:

• Oral contraceptives
• Long-acting injectable contraceptives
• Vaginal rings
• Hormone patches
• Certain drugs used to treat sexually transmitted diseases (STDs)

In compliance with Texas Insurance Code, Section 1369.1031, Medicaid provides up to a three-month supply of covered prescription contraceptive drugs the first time a client obtains the drug, then a 12-month supply at one time each subsequent time the client obtains the same drug. This does not apply to contraceptives under the clinician-administered drug benefit.

VDP defines the "same drug" as a drug that can be therapeutically substituted (for example, multiple formulations, strengths, and NDCs).

CSHCN Services Program

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

CHIP

CHIP covers birth control for certain diagnoses. Contraceptives are only covered for non-contraceptive medical purposes. Pharmacy providers should contact the client's MCO for details.

Medicaid clients are eligible for direct-acting antiviral (DAA) treatments for Hepatitis C infection. Clients do not have to meet specific METAVIR fibrosis scores, and HHSC does not require clinical prior authorization or illicit drug screenings. Any Medicaid-enrolled provider can prescribe DAA drugs.

HHSC partnered with AbbVie starting Jan. 1, 2023, to increase access to treatment. AbbVie’s product Mavyret is the Medicaid preferred DAA drug and is available without a preferred drug list (PDL) prior authorization. For any non-preferred DAA drugs, HHSC may continue to approve if the client meets at least one of the PDL prior authorization criteria . This applies to both fee-for-service and managed care. The PDL Criteria Guide explains the criteria used to evaluate the non-preferred prior authorization requests.

Refer to the VDP website Preferred Drug page to review the latest edition of the PDL for impacted drugs.

Prescribers may write prescriptions for the entire course of therapy, so clients do not need to request additional refills throughout their treatment duration. Prescribers may choose to write a prescription for the entire treatment cycle or have the client return for further testing if warranted. This quantity limit applies to all Hepatitis C DAA drugs.

Refer to the Formulary search and select “Hepatitis C Agents” from the “PDL Class” filter to identify these drugs.

HHSC provides specific home health supply products as a pharmacy benefit to clients enrolled in Medicaid, CHIP, the CSHCN Services Program, and KHC Program.  The covered products include the following:

• Aerosol Holding Chamber
• Diabetic Lancets
• Diabetic Monitor (talking)
• Diabetic Test Strips
• Hypertonic Salines
• Insulin Needles
• Insulin Syringes
• Oral Electrolyte Replacement Fluid
• Spring Powered Device for Lancet

CMS classifies these products as a Title XIX (Medicaid) home health benefit as either durable medical equipment (DME) or medical supplies. These supplies do not require prior authorization unless otherwise specified.

Pharmacies are not required to enroll as a Medicaid durable medical equipment (DME) provider to supply these products. Pharmacies already enrolled as Medicaid DME providers can submit claims as either a pharmacy benefit or medical benefit. Contact the Texas Medicaid and Healthcare Partnership (TMHP) for instructions about submitting medical claims.

A physician must prescribe all DME and home health supplies. Advanced practice registered nurses and physician assistants cannot prescribe these products to clients enrolled in Medicaid or CHIP.

A list of products is available through the Formulary search (txvendordrug.com/formulary/formulary-search). You can search by product name, the 11-digit NDC, or select the product from the HCPCS Description dropdown. Additional filters are available to find products payable by each program. Products not included in the search are only available through the Medicaid medical benefit.

HHSC

A prescription is required for HHSC to process pharmacy claims for clients enrolled in fee-for-service Medicaid, the CSHCN Services Program, and KHC Program. HHSC does not require the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form (TMHP Form F00030) for products dispensed by a pharmacy.

The claim system will reject products submitted as part of a multi-ingredient compound claim with NCPDP error code 70 ("Product/Service Not Covered") and include the message "LHHS products are not covered in a compound claim" in the "Additional Message Information" field (526-FQ).

The claim system will reject claims if the submitted quantity exceeds the maximum unit per filling with NCPDP error code 9G ("Product/Service Not Covered"). If the quantity submitted exceeds the maximum unit per month, the claim system will reject claims with NCPDP error code 76 ("Plan Limitation Exceeded").

If the claim exceeds quantity limits, pharmacy providers must attest the submitted quantity is the actual quantity prescribed based on medical necessity by submitting the following values:

Refer to the Claims Billing (B1) Transaction payer sheets for specific transaction, segment, and field requirements.

Refer to the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook chapter of the Texas Medicaid Provider Procedures Manual (tmhp.com/resources/provider-manuals/tmppm) for quantity guideline criteria. Refer to the information below for limitations impacting claims paid by HHSC.

Claims for Medicaid do not count towards a client's three prescription-per-month limit. Claims for KHC will count towards a client's four prescription-per-month limit.

HHSC bases its reimbursement rates on the "Home Health DME" Provider Type in the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule and does not reimburse pharmacies a dispensing fee or delivery incentive. Refer to the TMHP Static Fee Schedule page (public.tmhp.com/FeeSchedules/StaticFeeSchedule/FeeSchedules.aspx) for reimbursement rates.

HHSC does not require the TMHP DME Certification and Receipt Form (Form F00018) for pharmacy claims.

Managed care

Pharmacies submit claims for clients enrolled in Medicaid managed care and CHIP to the client's MCO. MCOs have the flexibility to manage a preferred home health supplies list for the limited home health supplies. Pharmacy providers should contact the client's specific MCO for details.

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 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.

Traditional Medicaid

HHSC requires prior authorization for Increlex (mecasermin). Prescribing providers complete and submit the Increlex Prior Authorization Request (HHS Form 1357).

Traditional Medicaid

During influenza season, pharmacies may bill for influenza vaccines provided to people 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 Texas State Board of Pharmacy's (TSBP) rules related to certification to immunize and vaccinate. Refer to TAC Section 295.15 (Chapter 295: 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 (txvendordrug.com/formulary/formulary-search) for a list of products.

Pharmacy providers should submit the values identified below. Refer to the Claims Billing (B1) Transaction for specific transaction, segment, and field requirements.

Medicaid managed care and CHIP

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. Pharmacies providers should contact the client's specific MCO for details.

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. Insulin syringes and needles are obtained with a physician's or allowed practitioner's prescription from a participating pharmacy and do not require prior authorization. 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.

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).

Pharmacists may administer long-acting injectable (LAI) antipsychotics and opioid antagonists to treat a substance or opioid use disorder in a pharmacy setting for people in Medicaid with a valid prescription. Pharmacists can administer medications under a physician's delegation as authorized by state law. Refer to Texas Occupation Code section 554.004 (Administration of Medication). Refer to the Formulary search to identify drugs eligible for administration in a pharmacy.

Traditional Medicaid

The pharmacy, not the 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 Claims Billing (B1) Transaction payer sheets for 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.

Medicaid 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. Pharmacy providers should contact the client's specific MCO for details.

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.

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).

HHSC covers mosquito repellents year-round for the prevention of the Zika virus and other related mosquito-borne diseases for clients enrolled in the following programs:

• Medicaid
• Children's Health Insurance Program (CHIP) and CHIP-Perinatal
• Children with Special Health Care Needs (CSHCN) Services Program
• Healthy Texas Women program (HTW)

HHSC selects products based on guidance from the Centers for Disease Control and Prevention (CDC). Products include the recommended amount of the active ingredient DEET, IR3535, oil of lemon eucalyptus, or Picaridi effective against the Zika virus.

Refer to the Formulary search (txvendordrug.com/formulary/formulary-search) for a list of products. Users can search by product name, the 11-digit NDC, or click the "mosquito repellent" checkbox for a list of all products.

Download the Mosquito Repellent Benefit Information to display information about the benefit in pharmacies or doctor offices. For more information about the Zika virus, refer to the following resources:

• Texas Department of State Health Services (texaszika.org)
• Zika Medicaid Benefit (hhs.texas.gov/services/health/zika-medicaid-benefit)
• CDC: Zika Virus (cdc.gov/zika)

Benefit Specifics

Clients eligible for the benefit include the following demographics:

• Females 10-55 years old
• Pregnant females of any age
• Males 14 and older

HHSC requires a prescription for all clients. Contact the client's health care provider to obtain a prescription for mosquito repellent.

Coverage of mosquito repellents is limited to two cans or bottles per calendar month. Pharmacies should dispense only one can or bottle per fill, with one optional refill available per calendar month.

Mosquito repellent claims do not count against a person's monthly three-prescription limit for people enrolled in traditional fee-for-service Medicaid.

Pharmacies will require a prescription from a valid healthcare provider before dispensing mosquito repellent to clients enrolled in Medicaid.

Other Medicaid benefits available in response to Zika virus prevention include oral contraceptives and long-acting reversible contraceptive products that help to prevent pregnancy. These are available as a Medicaid benefit to eligible individuals. Other covered benefits include family planning services, diagnostic testing, targeted case management, physical therapy, long-term services and support, acetaminophen, and oral electrolytes for Zika virus symptoms, and potential coverage for additional ultrasounds for pregnant women.

Claim Submission

Claims for mosquito repellent must use the client’s provider National Provider Identifier (NPI) as the prescriber NPI on the claim. HHSC converted each product's 12-digit universal product code (UPC) into an 11-digit NDC for claims submission. HHSC identifies mosquito repellents as a generic medication. Pharmacists have the authority to fill the prescription with any covered product unless the prescriber has stated "do not substitute" to specify the active ingredient.

The "Unit of Measure" field (600-28) determines the "Quantity Dispensed" field (442-E7). When processing mosquito repellent claims, pharmacy providers should submit the standard unit in the "Unit of Measure" field. For example, the pharmacy should submit a 170-gram bottle of mosquito repellent with a quantity of 170.

HHSC expects a can of repellent to last 15 days or more and recommends pharmacy providers submit a 15-day supply.

Pharmacy providers may request manual overrides of claims clients outside the eligibility requirements of pregnant women.

• Contact the HHSC Pharmacy Benefits Access Help Desk for clients enrolled in traditional Medicaid, CSHCN, and HTW programs
• Pharmacy providers should contact the client's specific MCO for details

Reimbursement

Pharmacies are required to submit their usual and customary cost for the items.

The traditional Medicaid reimbursement is the usual and customary price to the public or up to a maximum of $6.50 per can or bottle of mosquito repellent (inclusive of product cost and dispensing fee), with the total calendar month maximum of $13.00. Products are not eligible for delivery fees or incentive fees.

Reimbursement may vary between MCOs but may not exceed $6.50 per can or bottle.

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.

Prospective Safety Edits

HHSC performs the following Medicaid processes automatically during the pharmacy claims submission process.

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 MME

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 clients 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.

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.

Prospective Safety Edits

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

Fee-For-Service Three-prescription Limit

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

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 for more information about alerts.

HHSC provides coverage for over-the-counter (OTC) products for Medicaid clients. Specific coverage exceptions for OTC products include the following items when an OTC is an economical and therapeutic alternative to a prescription drug item:

• Analgesics
• Anti-emetics
• Anti-inflammatory agents
• Anti-parasitics
• Dermatological agents
• Enzyme replacements
• Gastrointestinal agents, including:
  • Antacids
  • H-2 antagonists
  • Laxatives
  • Proton pump inhibitors
• Insulin
• Ophthalmic agents
• Opiate dependence treatments
• Oral contraceptives
• Otic agents
• Respiratory agents

Traditional Medicaid, CSHCN Services Program, and KHC Program

HHSC covers some OTC drugs, except for clients residing in a nursing facility. 

CHIP

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

Traditional Medicaid

HHSC requires prior authorization for Oxycontin (oxycodone ER). Prescribing providers complete and submit the OxyContin Standard Prior Authorization Addendum (HHS Form 1353).

Traditional Medicaid

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

KHC Program

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).

Traditional Medicaid

HHSC requires prior authorization for non-preferred phosphate binder agents. Prescribing providers complete and submit the Phosphate Binders Standard Prior Authorization Addendum (HHS Form 1348).

Traditional Medicaid

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

Traditional Medicaid

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

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

Refer to the Formulary Search for the vitamins covered by Medicaid.

Traditional Medicaid

HHSC requires prior authorization for proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor agents.  The Food and Drug Administration approved these products for use with diet and adjunct treatment with maximally-tolerated statin therapy in adults with familial hypercholesterolemia or those with atherosclerotic cardiovascular disease (ASCVD) whose low-density lipoprotein cholesterol (LDL-C) is not adequately maintained with the current available treatments. The American Heart Association and American College of Cardiology recommends lifestyle modifications including a healthy diet and physical exercise to improve LDL-C levels.

Prescribing providers complete and submit the PCSK9 Inhibitors Standard Prior Authorization Addendum (HHS Form 1355).  Approvals for are granted for six months.

CSHCN Services Program

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

Human Respiratory Syncytial Virus (RSV) causes respiratory tract infections and serious lung disease in infants and children. Synagis (palivizumab) is available for children with high risk of infection.

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 previous 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.

Season Schedule

HHSC publishes the current RSV season on the VDP website, broken out by Texas public health region. Providers can find their region using the interaction region map (PDF) and selecting the buttons marked HHS regions and county names.

Pharmacy Information

Any specialty pharmacy enrolled with HHSC may provide Synagis. A pharmacy must enroll in the CSHCN Services Program to provide services to children in the program.

Traditional Medicaid

Prior authorization is a two-step process. The prescribing provider completes the following forms and submits them along with the prescription for Synagis and any supporting information to the Medicaid-enrolled pharmacy.

• Standard Prior Authorization Request
• Synagis Standard Prior Authorization Addendum (HHSC Form 1321)

Refer to the Prior Authorization Requests section for the forms. Failure to submit both forms will result in an authorization denial or delay.

Pharmacy providers then submit the form to the Texas Prior Authorization Call Center.

Medicaid managed care and CHIP

Pharmacy providers should contact the client's specific MCO for prior authorization requirements and forms. MCOs may require further information in addition to the MCO-specific addendum form. Each MCO will have its own addendum form, and it will reflect the MCO's contact information and reconsideration request process. Failure to submit all required forms will result in an authorization denial or delay.

CSHCN Services Program

Prior authorization is a two-step process. The prescribing provider completes the following forms and submits them along with the prescription for Synagis and any supporting information to the CSHCN-enrolled pharmacy.

• Standard Prior Authorization Request
• Synagis Standard Prior Authorization Addendum (HHSC Form 1325)

Refer to the Prior Authorization Requests section for the forms. Failure to submit both forms will result in an authorization denial or delay.

Pharmacy providers then submit the form to the CSHCN Services Program.

Traditional Medicaid

Smoking cessation products are exempt from the three-drug limit.

A free, state hotline offering telephone counseling for clients trying to quit smoking is also available. Clients can contact the Texas Quitline at 1-877-YES-QUIT (1-877-937-7848, available in multiple languages) or visit yesquit.org to receive counseling and services such as nicotine patches, gums, or lozenges that may be free to those who qualify.

Traditional Medicaid

Specialty drugs on the biannual Specialty Drug List (SDL) are available as either an outpatient pharmacy benefit, a medical or 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 or physician benefit. Contact TMHP for form submission requirements.

Medicaid managed care

HHSC provides the SDL to MCOs to identify specialty drugs offered exclusively through the MCO's specialty pharmacy network.

Refer to the Specialty Drug Handbook for the specialty drug rule, how to provide input for the SDL, and the SDL publication schedule.

KHC Program

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).

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).

HHSC provides specific vitamin and mineral products as a pharmacy benefit to clients 20 years or younger and enrolled in Medicaid, and the CSHCN Services Program. The products are also available through the Medicaid Comprehensive Care Program (CCP) as a medical benefit.

Pharmacies are not required to enroll in the CCP or as a Medicaid durable medical equipment (DME) provider to supply these products. Pharmacies already enrolled as Medicaid CCP or DME providers can submit claims as a pharmacy benefit or medical benefit. Contact the Texas Medicaid and Healthcare Partnership (TMHP) for instructions about submitting medical claims.

Prescribing providers enrolled with Medicaid as DME providers should continue to submit claims for traditional Medicaid clients to TMHP. Refer to the Children's Services Handbook of the Texas Medicaid Provider Procedures Manual (tmhp.com/resources/provider-manuals/tmppm).

A list of products is available through the Product search (txvendordrug.com/formulary/formulary-search). You can search by product name, the 11-digit NDC, or click the "vitamin and mineral" checkbox. Additional filters are available to find products payable by each program. A list of products and their associated condition are below.

The Medicaid CCP may pay for products not available on the search for clients enrolled in traditional Medicaid for particular medical conditions.

HHSC

A prescription is required for HHSC to process pharmacy claims for clients enrolled in fee-for-service Medicaid and the CSHCN Services Program.

HHSC does not require the TMHP CCP Prior Authorization Request Form for products dispensed by a pharmacy. Refer to the Durable Medical Equipment, Medical Supplies, and Nutritional Products Handbook of the Texas Medicaid Provider Procedures Manual (tmhp.com/resources/provider-manuals/tmppm) for quantity guideline criteria.

Claims for traditional Medicaid do not count towards a client's three prescription-per-month limit.

HHSC sets the reimbursement rate at the Average Wholesale Price minus 10.5 percent, minus 8 percent. Pharmacies do not receive a dispensing fee or delivery incentive.

Multi-ingredient compound claims submitted with vitamin or mineral products are not payable. HHSC may consider some compound claims for coverage through CCP.

Claims are limited to a 30-day supply. Pharmacy providers should contact HHSC for liquid formulations greater than this limit. Pharmacies should not dispense refills until the client uses 100% of the supply. Prescriptions are valid for six months after the date written.

The pharmacy must acknowledge the prescribed product is for a medically accepted indication according to the current vitamin and mineral policy by submitting the following values:

HHSC does not require the DME Certification and Receipt Form (TMHP Form F00018) for pharmacy claims.

Managed care

Pharmacies submit claims for clients enrolled in Medicaid managed care and CHIP to the client's MCO. Pharmacies providers should contact the client's specific MCO for details.

Medicaid

Social Security Act Section 1927 (d)(2) and Texas Administrative Code section 354.1923 allow HHSC to prohibit or restrict coverage of weight management drugs. HHSC provides coverage for certain weight management drugs for Medicaid. Specific coverage exceptions for weight management drugs include appetite stimulants, anorexic agents, and fat absorption-decreasing agents.

Weight management drugs (excluding specific coverage exceptions) are not covered for clients enrolled in traditional Medicaid who are 21 years and over. 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). HHSC clinician staff determine coverage, and no form is required.

Traditional Medicaid

HHSC requires prior authorization for Xyrem. Prescribing providers complete and submit the Xyrem Prior Authorization Request (HHS Form 1356).