The HHSC drug rebate system receives all outpatient pharmacy and clinician-administered drug claims for all state-administered programs for invoicing. HHSC invoices drug manufacturers for claims when the state pays any amount after deductions for co-pay, coinsurance, or any other payment type. Any amount paid for dual-eligible clients, either directly by the state or through an MCO, is also invoiced if the state pays any amount.

Pharmacy Rebates Exclusions

HHSC only excludes pharmacy claims from the rebate collection process if the pharmacy submits a "20" in the "Submission Clarification Code" field (420-DK), required as of Jan. 1, 2014. It is the responsibility of the covered entity and their contracted pharmacies to correctly report claims filled with 340B stock for 340B-eligible clients to ensure the state does not collect rebates for these drugs.

Clinician-Administered Drug Rebates Exclusions

HHSC only excludes medical claims for outpatient clinician-administered drug claims from the rebate collection process if the provider submits the U8 modifier. It is the responsibility of the provider to correctly report claims identified as 340B stock for 340B-eligible clients to ensure the state does not collect rebates for these drugs.